Medical Coding

and Billing Specialist

Instruction Pack 3 Lessons 21-30

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Explore the possibilities ®
0205502LB03A-13
Medical Coding
and Billing
Specialist
Instruction Pack 3

Lesson 21—Solving Problems with Insurance

Carriers, Providers and Patients
Lesson 22—Coding and Billing Resources
Lesson 23—ICD-9-CM Coding Introduction
Lesson 24—ICD-9-CM Coding—From
Infections to Blood Diseases
Lesson 25—ICD-9-CM Coding—From Mental
Disorders to Circulatory System
Lesson 26—ICD-9-CM Coding—From
Respiratory System to
Complications of Pregnancy
Lesson 27—ICD-9-CM Coding—From Diseases
of the Skin to Conditions in the
Perinatal Period
Lesson 28—ICD-9-CM Coding—From
Symptoms to Complications
Lesson 29—V Codes, E Codes and ICD-9-CM
Coding Practicum
Lesson 30—The Future of Health Care
 Medical Coding and Billing Specialist

No part of this document may be reproduced or transmitted in any form or by any means,
electronic or mechanical, for any purpose, without the express written permission of
U.S. Career Institute.

Copyright © 2012-2013, Weston Distance Learning, Inc. All Rights Reserved.

0205502LB03A-13

Acknowledgments

Author
Katy Little

Editorial Staff
Trish Bowen
Katy Little
Leslie Ballentine
Elizabeth Munson
Bridget Tisthammer
Kathy DeVault
Georgia Chaney
Brenda Blomberg
Stephanie MacLeod
Chris Jones
Sue Bentley
Carrie Williams
Joyce Jeckewicz
Jessica Tuttle

Design/Layout
Connie Hunsader
Sandy Petersen
D. Brent Hauseman

FOR MORE INFORMATION CONTACT:

U.S. Career Institute
Fort Collins, CO 80525 • 1-800-347-7899
www.uscareerinstitute.edu

0205502LB03A-13
 Table of Contents

Table of Contents
Lesson 21—Solving Problems with
Insurance Carriers, Providers and Patients
Step 1 Learning Objectives for Lesson 21 ........................................................... 1
Step 2 Lesson Preview.......................................................................................... 1
Step 3 Dealing With Insurance Problems ........................................................... 2
Step 4 Following Through on Insurance Problems............................................. 3
Resubmitting a Paper Claim .................................................................... 3
Resubmitting an Electronic Claim ........................................................... 5
Sending a Tracer ....................................................................................... 5
Filing a Narrative Explanation ................................................................ 7
Appeals ...................................................................................................... 8
The Insurance Commissioner................................................................. 10
Rejected Versus Denied Claims ............................................................. 10
Step 5 Practice Exercise 21-1 ............................................................................. 11
Step 6 Review Practice Exercise 21-1................................................................ 11
Step 7 Billing Patients ....................................................................................... 11
Step 8 Credit ....................................................................................................... 12
Your Credit Report.................................................................................. 13
Step 9 Delinquent Accounts ............................................................................... 15
Handling Returned Checks .................................................................... 15
Handling Nonpayment ........................................................................... 16
Step 10 Collection Agencies ................................................................................. 18
Using Collection Agencies ...................................................................... 18
Step 11 Small Claims Court ................................................................................ 19
Filing a Claim.......................................................................................... 19
Collecting a Judgment ............................................................................ 20
Step 12 Solving Patient Problems ....................................................................... 20
Step 13 Solving Problems With Providers .......................................................... 22
Step 14 Professional Liability Insurance ............................................................ 22
Step 15 How Does Compliance Affect Medical Coders and Billers? .................. 23
Elements of Compliance ......................................................................... 23
Step 16 Practice Exercise 21-2 ............................................................................. 25
Step 17 Review Practice Exercise 21-2................................................................ 26
Step 18 Lesson Summary..................................................................................... 26
Business Forms for a Medical Coding and Billing Specialist ............... 27
Step 19 Mail-in Quiz 21 ....................................................................................... 40
Mail-in Quiz 21 ....................................................................................... 40

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Medical Coding and Billing Specialist

Lesson 22—Coding and Billing Resources

Step 1 Learning Objectives for Lesson 22 ........................................................... 1
Step 2 Lesson Preview.......................................................................................... 1
Step 3 Associations for Professional Coders and Billers .................................... 2
Step 4 Credentialing............................................................................................. 5
Step 5 Practice Exercise 22-1 ............................................................................... 8
Step 6 Review Practice Exercise 22-1.................................................................. 9
Step 7 Coding and Billing Resources................................................................... 9
Step 8 Practice Exercise 22-2 ............................................................................. 15
Step 9 Review Practice Exercise 22-2................................................................ 15
Step 10 Lesson Summary..................................................................................... 15
Step 11 Mail-in Quiz 22 ....................................................................................... 16
Mail-in Quiz 22 ....................................................................................... 16
Endnotes .................................................................................................. 19

Lesson 23—ICD-9-CM Coding Introduction

Step 1 Learning Objectives for Lesson 23 ........................................................... 1
Step 2 Lesson Preview.......................................................................................... 1
Step 3 History of the International Classification of Diseases .......................... 2
The WHO ................................................................................................... 3
ICD-9-CM .................................................................................................. 3
Step 4 Why Code? ................................................................................................. 4
Step 5 ICD-10 ....................................................................................................... 5
Impact for Coders ...................................................................................... 6
Step 6 ICD-9-CM vs. ICD-10-CM ........................................................................ 6
Step 7 Practice Exercise 23-1 ............................................................................... 7
Step 8 Review Practice Exercise 23-1.................................................................. 8
Step 9 Organization of Volume 2, Alphabetic Index to Diseases ICD-9-CM...... 8
Main Terms ............................................................................................. 9
Subterms ................................................................................................. 10
Step 10 Organization of Volume 1, Tabular List ................................................ 12
Step 11 Practice Exercise 23-2 ............................................................................. 15
Step 12 Review Practice Exercise 23-2................................................................ 16
Step 13 Introduction to Coding Guidelines ......................................................... 16
Cross-reference Terms ........................................................................... 18
Step 14 Practice Exercise 23-3 ............................................................................. 28
Step 15 Review Practice Exercise 23-3................................................................ 29
Step 16 ICD-9-CM Terminology .......................................................................... 29

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Step 17 The Appendices ....................................................................................... 31

Appendix A—Morphology of Neoplasms................................................ 31
Appendix B—Glossary of Mental Disorders .......................................... 31
Appendix C—Classification of Drugs by AHFS List ............................. 31
Appendix D—Industrial Accidents According to Agency...................... 32
Appendix E—List of Three-Digit Categories ......................................... 32
Step 18 Practice Exercise 23-4 ............................................................................. 33
Step 19 Review Practice Exercise 23-4................................................................ 33
Step 20 The Steps to Correct Coding................................................................... 33
Steps for Assigning Diagnostic Codes .................................................... 34
Practice Makes Perfect ........................................................................... 35
Step 21 Pathways ................................................................................................. 36
Step 22 Clinical Applications of Coding Rules .................................................... 37
Inpatients and Outpatients .................................................................... 38
Step 23 Practice Exercise 23-5 ............................................................................. 39
Step 24 Review Practice Exercise 23-5................................................................ 41
Step 25 Lesson Summary..................................................................................... 41
Step 26 Mail-in Quiz 23 ....................................................................................... 42
Mail-in Quiz 23 ....................................................................................... 42

Lesson 24—ICD-9-CM Coding—

From Infections to Blood Diseases
Step 1 Learning Objectives for Lesson 24 ........................................................... 1
Step 2 Lesson Preview.......................................................................................... 1
Step 3 Infectious and Parasitic Diseases (001-139), Part 1...................................... 3
Intestinal Infectious Diseases (001-009) ................................................. 3
Tuberculosis (010-018) .............................................................................. 4
Zoonotic Bacterial Diseases (020-027) ..................................................... 6
Other Bacterial Diseases (030-041) ......................................................... 6
Human Immunodeficiency Virus (HIV) Infection (042) .......................... 7
Step 4 Practice Exercise 24-1 ............................................................................. 10
Step 5 Review Practice Exercise 24-1................................................................ 14
Step 6 Infectious and Parasitic Diseases (001-139), Part 2 ............................. 14
Poliomyelitis and Other Non-Arthropod-Borne Viral Diseases
and Prion Diseases of Central Nervous System (045-049) .............. 14
Viral Diseases Generally Accompanied by Exanthem (050-059) ......... 15
Arthropod-Borne Viral Diseases (060-066)............................................ 15
Other Diseases Due to Viruses and Chlamydiae (070-079).................. 16
Rickettsioses and Other Arthropod-Borne Diseases (080-088) ............ 17
Step 7 Practice Exercise 24-2 ............................................................................. 17

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Medical Coding and Billing Specialist

Step 8 Review Practice Exercise 24-2................................................................ 18

Step 9 Infectious and Parasitic Diseases (001-139), Part 3 ............................. 18
Syphilis and Other Venereal Diseases (090-099) .................................. 18
Other Spirochetal Diseases (100-104).................................................... 19
Mycoses (110-118) ................................................................................... 20
Helminthiases (120-129)......................................................................... 20
Other Infectious and Parasitic Diseases (130-136) ............................... 21
Late Effects of Infectious and Parasitic Diseases (137-139) ................. 21
Step 10 Practice Exercise 24-3 ............................................................................. 21
Step 11 Review Practice Exercise 24-3................................................................ 26
Step 12 Neoplasms (140-239) ............................................................................... 26
Malignant Neoplasms (140-208) ............................................................ 28
Neuroendocrine Tumors (209) ............................................................... 29
Benign Neoplasms (210-229) ................................................................. 30
Carcinoma in Situ (230-234) .................................................................. 30
Neoplasms of Uncertain Behavior (235-238) ......................................... 31
Neoplasms of Unspecified Nature (239) ................................................ 31
Step 13 Practice Exercise 24-4 ............................................................................. 32
Step 14 Review Practice Exercise 24-4................................................................ 33
Step 15 Endocrine, Nutritional and Metabolic Diseases,
and Immunity Disorders (240-279) ................................................... 33
Disorders of Thyroid Gland (240-246) ................................................... 33
Diseases of Other Endocrine Glands (249-259) ..................................... 34
Nutritional Deficiencies (260-269) ......................................................... 37
Other Metabolic and Immunity Disorders (270-279) ............................ 38
Step 16 Diseases of the Blood and Blood-Forming Organs (280-289) ............... 38
Step 17 Practice Exercise 24-5 ............................................................................. 41
Step 18 Review Practice Exercise 24-5................................................................ 45
Step 19 Lesson Summary..................................................................................... 45
Step 20 Mail-in Quiz 24 ....................................................................................... 45
Mail-in Quiz 24 ....................................................................................... 46
Endnote ................................................................................................... 51

Lesson 25—ICD-9-CM Coding—

From Mental Disorders to Circulatory System
Step 1 Learning Objectives for Lesson 25 ........................................................... 1
Step 2 Lesson Preview.......................................................................................... 1
Step 3 Mental, Behavioral and Neurodevelopmental Disorders (290-319) ....... 2

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Psychoses (290-299) .................................................................................. 2

Neurotic Disorders, Personality Disorders, and
Other Nonpsychotic Mental Disorders (300-316) .............................. 5
Intellectual Disabilities (317-319) ............................................................ 7
Step 4 Practice Exercise 25-1 .............................................................................. 7
Step 5 Review Practice Exercise 25-1................................................................ 11
Step 6 Diseases of the Nervous System and Sense Organs (320-389), Part 1... 11
Inflammatory Diseases of the Central Nervous System (320-326) ...... 12
Hereditary and Degenerative Diseases of the
Central Nervous System (330-337)................................................... 13
Other Headache Syndromes (339) ......................................................... 15
Other Disorders of the Central Nervous System (340-349) .................. 15
Disorders of the Peripheral Nervous System (350-359) ....................... 18
Step 7 Practice Exercise 25-2 ............................................................................. 19
Step 8 Review Practice Exercise 25-2................................................................ 23
Step 9 Diseases of the Nervous System and Sense Organs (320-389), Part 2... 23
Disorders of the Eye and Adnexa (360-379) .......................................... 23
Diseases of the Ear and Mastoid Process (380-389).............................. 27
Step 10 Practice Exercise 25-3 ............................................................................. 30
Step 11 Review Practice Exercise 25-3................................................................ 31
Step 12 Diseases of the Circulatory System (390-459), Part 1 .......................... 31
Acute Rheumatic Fever (390-392) .......................................................... 31
Chronic Rheumatic Heart Disease (393-398) ........................................ 32
Hypertensive Disease (401-405) ............................................................. 33
Ischemic Heart Disease (410-414).......................................................... 36
Step 13 Practice Exercise 25-4 ............................................................................. 38
Step 14 Review Practice Exercise 25-4................................................................ 39
Step 15 Diseases of the Circulatory System (390-459), Part 2 .......................... 40
Diseases of Pulmonary Circulation (415-417) ....................................... 40
Other Forms of Heart Disease (420-429) ............................................... 40
Cerebrovascular Disease (430-438) ........................................................ 41
Diseases of Arteries, Arterioles, and Capillaries (440-449) .................. 44
Diseases of Veins and Lymphatics, and Other
Diseases of the Circulatory System (451-459) ................................. 45
Step 16 Practice Exercise 25-5 ............................................................................. 45
Step 17 Review Practice Exercise 25-5................................................................ 46
Step 18 Lesson Summary..................................................................................... 47
Step 19 Mail-in Quiz 25 ....................................................................................... 47
Mail-in Quiz 25 ....................................................................................... 48

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Lesson 26—ICD-9-CM Coding—

From Respiratory System to
Complications of Pregnancy
Step 1 Learning Objectives for Lesson 26 ........................................................... 1
Step 2 Lesson Preview.......................................................................................... 1
Step 3 Diseases of the Respiratory System (460-519) ........................................ 2
Acute Respiratory Infections (460-466) ................................................... 2
Other Diseases of the Upper Respiratory Tract (470-478) ..................... 4
Pneumonia and Influenza (480-488) ........................................................ 4
Chronic Obstructive Pulmonary Disease and Allied
Conditions (490-496)............................................................................ 6
Pneumoconioses and Other Lung Diseases due to
External Agents (500-508) .................................................................. 9
Other Diseases of the Respiratory System (510-519) ........................... 10
Step 4 Practice Exercise 26-1 ............................................................................. 11
Step 5 Review Practice Exercise 26-1................................................................ 12
Step 6 Diseases of the Digestive System (520-579) .......................................... 12
Diseases of Oral Cavity, Salivary Glands, and Jaws (520-529) ........... 12
Diseases of Esophagus, Stomach, and Duodenum (530-539) ............... 14
Appendicitis (540-543) ............................................................................ 16
Hernia of Abdominal Cavity (550-553) .................................................. 16
Noninfectious Enteritis and Colitis (555-558) ....................................... 18
Other Diseases of Intestines and Peritoneum (560-569) ...................... 18
Other Diseases of Digestive System (570-579) ...................................... 20
Step 7 Practice Exercise 26-2 ............................................................................. 21
Step 8 Review Practice Exercise 26-2................................................................ 23
Step 9 Diseases of the Genitourinary System (580-629) .................................. 23
Nephritis, Nephrotic Syndrome, and Nephrosis (580-589) .................. 24
Other Diseases of Urinary System (590-599) ........................................ 24
Diseases of Male Genital Organs (600-608) .......................................... 26
Disorders of Breast (610-612) ................................................................. 28
Inflammatory Disease of Female Pelvic Organs (614-616)................... 29
Step 10 Practice Exercise 26-3 ............................................................................. 32
Step 11 Review Practice Exercise 26-3................................................................ 36
Step 12 Complications of Pregnancy, Childbirth,
and the Puerperium (630-679) .......................................................... 36
ICD-9-CM Guidelines: General Rules for Obstetric Cases ................... 36
Ectopic and Molar Pregnancy (630-633) ................................................ 37
Other Pregnancy with Abortive Outcome (634-639) ............................. 37

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Complications Mainly Related to Pregnancy (640-649) ........................ 38

Normal Delivery, and Other Indications for Care in
Pregnancy, Labor, and Delivery (650-659) ....................................... 39
Complications Occurring Mainly in the Course of Labor
and Delivery (660-669) ...................................................................... 41
Complications of the Puerperium (670-677) .......................................... 45
Step 13 Practice Exercise 26-4 ............................................................................. 47
Step 14 Review Practice Exercise 26-4................................................................ 48
Step 15 Lesson Summary..................................................................................... 49
Step 16 Mail-in Quiz 26 ....................................................................................... 49
Mail-in Quiz 26 ....................................................................................... 49
Just for Fun ............................................................................................. 56

Lesson 27—ICD-9-CM Coding—

From Diseases of the Skin to Conditions
in the Perinatal Period
Step 1 Learning Objectives for Lesson 27 ........................................................... 1
Step 2 Lesson Preview.......................................................................................... 1
Step 3 Diseases of the Skin and Subcutaneous Tissue (680-709) ...................... 2
Infections of Skin and Subcutaneous Tissue (680-686) .......................... 3
Other Inflammatory Conditions of Skin and
Subcutaneous Tissue (690-698) ......................................................... 4
Other Diseases of Skin and Subcutaneous Tissue (700-709) ................ 4
Step 4 Practice Exercise 27-1 ............................................................................... 7
Step 5 Review Practice Exercise 27-1................................................................ 11
Step 6 Diseases of the Musculoskeletal System
and Connective Tissue (710-739) ...................................................... 11
Arthropathies and Related Disorders (710-719) ................................... 11
Dorsopathies (720-724) .......................................................................... 14
Rheumatism, Excluding the Back (725-729) ........................................ 15
Osteopathies, Chondropathies, and Acquired
Musculoskeletal Deformities (730-739) ........................................... 16
Step 7 Practice Exercise 27-2 ............................................................................. 17
Step 8 Review Practice Exercise 27-2................................................................ 21
Step 9 Congenital Anomalies (740-759) ............................................................ 21
Step 10 Practice Exercise 27-3 ............................................................................. 26
Step 11 Review Practice Exercise 27-3................................................................ 28
Step 12 Certain Conditions Originating in the Perinatal Period (760-779)...... 28
Maternal Causes of Perinatal Morbidity and Mortality (760-763) ..... 28

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Other Conditions Originating in the Perinatal Period (764-779) ....... 30

Step 13 Practice Exercise 27-4 ............................................................................. 34
Step 14 Review Practice Exercise 27-4................................................................ 34
Step 15 Lesson Summary..................................................................................... 35
Step 16 Mail-in Quiz 27 ....................................................................................... 35
Mail-in Quiz 27 ....................................................................................... 35

Lesson 28—ICD-9-CM Coding—

From Symptoms to Complications
Step 1 Learning Objectives for Lesson 28 ........................................................... 1
Step 2 Lesson Preview.......................................................................................... 1
Step 3 Symptoms, Signs, and Ill-Defined Conditions (780-799) ........................ 2
Symptoms (780-789) ................................................................................. 2
Nonspecific Abnormal Findings (790-796) ............................................. 13
Ill-Defined and Unknown Causes of Morbidity and
Mortality (797-799) ............................................................................ 13
Step 4 Practice Exercise 28-1 ............................................................................. 14
Step 5 Review Practice Exercise 28-1................................................................ 18
Step 6 Injury and Poisoning (800-999) Part 1................................................... 18
Fractures (800-829) ................................................................................. 19
Dislocation (830-839) .............................................................................. 28
Sprains and Strains of Joints and Adjacent Muscles (840-848) ........... 29
Intracranial Injury, Excluding Those with Skull Fracture (850-854) .... 29
Internal Injury of Thorax, Abdomen, and Pelvis (860-869) .................. 30
Step 7 Practice Exercise 28-2 ............................................................................. 31
Step 8 Review Practice Exercise 28-2................................................................ 33
Step 9 Injury and Poisoning (800-999) Part 2................................................... 34
Open Wound (870-897) ........................................................................... 34
Injury to Blood Vessels (900-904)........................................................... 35
Late Effects of Injuries, Poisonings, Toxic Effects, and
Other External Causes (905-909) ..................................................... 36
Superficial Injury (910-919) ................................................................... 36
Contusion with Intact Skin Surface (920-924) ...................................... 36
Crushing Injury (925-929) ...................................................................... 37
Effects of Foreign Body Entering Through Orifice (930-939) ............... 37
Burns (940-949) ....................................................................................... 37
Injury to Nerves and Spinal Cord (950-957) ......................................... 40
Certain Traumatic Complications and Unspecified Injuries (958-959) ... 40
Poisoning by Drugs, Medicinal, and Biological Substances (960-979) ... 40

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Toxic Effects of Substances Chiefly Nonmedicinal

As to Source (980-989) ....................................................................... 42
Other and Unspecified Effects of External Causes (990-995) .............. 42
Complications of Surgical and Medical Care,
Not Elsewhere Classified (996-999) .................................................. 44
Step 10 Practice Exercise 28-3 ............................................................................. 45
Step 11 Review Practice Exercise 28-3................................................................ 49
Step 12 Lesson Summary..................................................................................... 49
Step 13 Mail-in Quiz 28 ....................................................................................... 49
Mail-in Quiz 28 ....................................................................................... 50

Lesson 29—V Codes, E Codes and

ICD-9-CM Coding Practicum
Step 1 Learning Objectives for Lesson 29 ........................................................... 1
Step 2 Lesson Preview.......................................................................................... 1
Step 3 Supplementary Classification of Factors Influencing Health Status
and Contact with Health Services (V01-V91) .................................... 2
Persons with Potential Health Hazards Related to
Communicable Diseases (V01-V06) .................................................... 2
Persons with Need for Isolation, Other Potential
Health Hazards and Prophylactic Measures (V07-V09) ................... 4
Persons with Potential Health Hazards Related to
Personal and Family History (V10-V19) ............................................ 4
Persons Encountering Health Services in Circumstances
Related to Reproduction and Development (V20-V29) ...................... 4
Persons with a Condition Influencing Their Health Status (V40-V49).... 6
Persons Encountering Health Services for Specific
Procedures and Aftercare (V50-V59) .................................................. 6
Persons Encountering Health Services in
Other Circumstances (V60-V69) ......................................................... 6
Persons Without Reported Diagnosis Encountered During
Examination and Investigation of Individuals
and Populations (V70-V82) ................................................................. 7
Step 4 Practice Exercise 29-1 ............................................................................... 8
Step 5 Review Practice Exercise 29-1.................................................................. 9
Step 6 Supplementary Classification of External Causes
of Injury and Poisonings (E000-E999) .............................................. 10
Step 7 Practice Exercise 29-2 ............................................................................. 11
Step 8 Review Practice Exercise 29-2................................................................ 12
Step 9 Practicum Preview .................................................................................. 12

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Step 10 Guidelines for Assigning Codes.............................................................. 12

Steps for Assigning Diagnostic Codes .................................................... 13
Sequencing ICD-9-CM Codes ................................................................. 14
Step 11 Practice Exercises 29-3, 29-4 ................................................................. 15
Practice Exercise 29-3 ............................................................................ 15
Practice Exercise 29-4 ............................................................................. 15
Step 12 Review Practice Exercises 29-3, 29-4 .................................................... 16
Step 13 Practice Exercises 29-5, 29-6 .................................................................. 16
Practice Exercise 29-5 ............................................................................. 16
Practice Exercise 29-6 ............................................................................. 17
Step 14 Review Practice Exercises 29-5, 29-6 ..................................................... 17
Step 15 Practice Exercises 29-7, 29-8, 29-9......................................................... 18
Practice Exercise 29-7 ............................................................................. 18
Practice Exercise 29-8 ............................................................................. 20
Practice Exercise 29-9 ............................................................................. 21
Step 16 Review Practice Exercises 29-7, 29-8, 29-9............................................ 21
Step 17 Practice Exercises 29-10, 29-11, 29-12................................................... 22
Practice Exercise 29-10 ........................................................................... 22
Practice Exercise 29-11 .......................................................................... 22
Practice Exercise 29-12 .......................................................................... 23
Step 18 Review Practice Exercises 29-10, 29-11,29-12....................................... 23
Step 19 Lesson Summary..................................................................................... 23
Step 20 Mail-in Quiz 29 ....................................................................................... 24
Mail-in Quiz 29 ....................................................................................... 24

Lesson 30—The Future of Health Care

Step 1 Learning Objectives for Lesson 30 ........................................................... 1
Step 2 Lesson Preview.......................................................................................... 1
Step 3 Technology and Health Care: Today ........................................................ 2
Step 4 Electronic Health Records ........................................................................ 4
Step 5 Access the Internet and the Web from a Computer ................................ 6
The Computer Network ............................................................................ 7
Step 6 Electronic Coding ...................................................................................... 9
Encoder Programs ..................................................................................... 9
Computer-assisted Coding...................................................................... 12
Step 7 Web-based Coding ................................................................................... 14
Step 8 Practice Exercise 30-1 ............................................................................. 17

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Step 9 Review Practice Exercise 30-1................................................................ 17

Step 10 Lesson Summary..................................................................................... 17
Step 11 Mail-in Quiz 30 ....................................................................................... 18
Mail-in Quiz 30 ....................................................................................... 18
Endnotes .................................................................................................. 22

Answer Key
Lesson 21 ................................................................................................................... 1
Practice Exercise 21-1 ............................................................................... 1
Practice Exercise 21-2 ............................................................................... 1
Lesson 22 ................................................................................................................... 2
Practice Exercise 22-1 ............................................................................... 2
Practice Exercise 22-2 ............................................................................... 2
Lesson 23 ................................................................................................................... 3
Practice Exercise 23-1 ............................................................................... 3
Practice Exercise 23-2 ............................................................................... 3
Practice Exercise 23-3 ............................................................................... 4
Practice Exercise 23-4 ............................................................................... 4
Practice Exercise 23-5 ............................................................................... 5
Lesson 24 ................................................................................................................... 7
Practice Exercise 24-1 ............................................................................... 7
Practice Exercise 24-2 ............................................................................... 9
Practice Exercise 24-3 ............................................................................. 10
Practice Exercise 24-4 ............................................................................. 12
Practice Exercise 24-5 ............................................................................. 13
Lesson 25 ................................................................................................................. 15
Practice Exercise 25-1 ............................................................................. 15
Practice Exercise 25-2 ............................................................................. 17
Practice Exercise 25-3 ............................................................................. 19
Practice Exercise 25-4 ............................................................................. 20
Practice Exercise 25-5 ............................................................................. 21
Lesson 26 ................................................................................................................. 22
Practice Exercise 26-1 ............................................................................. 22
Practice Exercise 26-2 ............................................................................. 23
Practice Exercise 26-3 ............................................................................. 24
Practice Exercise 26-4 ............................................................................. 27

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Lesson 27 ................................................................................................................. 29
Practice Exercise 27-1 ............................................................................. 29
Practice Exercise 27-2 ............................................................................. 32
Practice Exercise 27-3 ............................................................................. 34
Practice Exercise 27-4 ............................................................................. 36
Lesson 28 ................................................................................................................. 38
Practice Exercise 28-1 ............................................................................. 38
Practice Exercise 28-2 ............................................................................. 40
Practice Exercise 28-3 ............................................................................. 41
Lesson 29 ................................................................................................................. 45
Practice Exercise 29-1 ............................................................................. 45
Practice Exercise 29-2 ............................................................................. 46
Practice Exercise 29-3 ............................................................................. 47
Practice Exercise 29-4 ............................................................................. 47
Practice Exercise 29-5 ............................................................................. 47
Practice Exercise 29-6 ............................................................................. 48
Practice Exercise 29-7 ............................................................................. 48
Practice Exercise 29-8 ............................................................................. 49
Practice Exercise 29-9 ............................................................................. 49
Practice Exercise 29-10 ........................................................................... 49
Practice Exercise 29-11 ........................................................................... 49
Practice Exercise 29-12 ........................................................................... 50
Lesson 30 ................................................................................................................. 50
Practice Exercise 30-1 ............................................................................. 50

xii 0205502LB03A-13
 Lesson 21

Introduction to
Solving
MedicalProblems with
Terminology:
InsuranceWord
Carriers,
PartsProviders
and Patients
 Step 1 Learning Objectives for Lesson 21
 When you have completed the instruction in this lesson, you will be trained to do the following:
 Describe the steps needed to solve problems with insurance companies.

 Explain how to handle misunderstandings and problems with providers and patients.

 Discuss the possible approaches to pursue with each type of problem.

 Describe what credit is and what an agreement to furnish credit contains.

 Explain how to keep your own credit record clean.

 Describe the options available to you if a client owes you money.

 Step 2 Lesson Preview

 In a perfect world, perfect people would always come through. You
would have no problems or misunderstandings. People wouldn’t
lose things or forget to complete tasks. Of course, we all know
we don’t live in a perfect world. As a professional business
person, you should always strive for perfection and expect
others to do the same. However, no matter how hard you and
others try to do a good job, something is bound to happen
from time to time; everyone has a bad day now and then.

When a problem occurs, you need to know how to deal

effectively with it. If you made the error, accept the blame
and work to fix the situation. If you are trying to solve
a problem created by someone else, you need to work
through the difficulty constructively. This lesson
will show you effective ways to solve problems with
insurance companies, doctors and patients. After
Everyone has a bad day now and then.
reading this lesson, you will be better prepared to
tackle any problem. So move on to the next step—and
you’ll learn how to make your world a little better!

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Medical Coding and Billing Specialist

 Step 3 Dealing With Insurance Problems

 Generally speaking, insurance companies are large businesses operating across the
nation. Consequently, claims that you file might occasionally be delayed. If you have
waited more than 30 days for reimbursement of a claim, you need to inquire about
it. To do this, you will need to find a contact who handles claim questions for the
insurance company that delayed the reimbursement.

Sometimes this contact is a person assigned to your geographical area such as a

regional representative. Or the contact might be located in the insurance company’s
home office. Some insurance companies have entire departments dedicated to
answering questions, so you might have a contact telephone number instead of a
single person. In any case, when you contact an insurance company regarding a
claim, you should have access to the claim when you call. This enables you to answer
any questions the insurance representative may have about the claim.

Why should you get in touch with the insurance company that has delayed
reimbursement? There are some very specific situations that call for an inquiry.
Here are some examples.

Insurance Problems
You need to call the insurance company to make an inquiry when any of these
situations occur:
 A claim is more than 30 days old and has had no explanation and
no reimbursement issued.
 A claim has been delayed 30 days or more and the insurance
company has notified you of an ongoing “investigation into the claim.”
 You believe the reimbursement received is incorrect, or a claim has
been denied and you don’t understand why.
 The explanation of benefits is missing.
 Reimbursement is received for a claim you haven’t filed.

The last situation listed in the box—reimbursement is received for a claim you haven’t
filed for—happens more often than you might think, but there are legitimate reasons.
For example, the insurance policy might be in a parent’s name and covers the child. If
the parent’s and child’s last names are the same, this isn’t likely to cause any confusion.
However, that isn’t always the case. Mary Jones’s policy, for example, might cover her
daughter, Julianna Cervantes. If the claim is in Julianna’s name at the office, but the
insurance company issues reimbursement for Mary Jones (the name on the policy), you
might have to inquire to find out exactly who this reimbursement covers.

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 Solving Problems with Insurance Carriers, Providers and Patients

Once you have called the insurance company regarding the claim, you may be
asked to do some follow-up work. You might simply have to resubmit the claim, or
you might send a tracer, which we will discuss shortly. If the insurance company
has questions about the claim, it might ask for a narrative. The following section
describes these activities.

 Step 4 Following Through on Insurance Problems

 When problems arise from insurance claims, you will be expected to deal with them.
Let’s look at some of the techniques you can use to address these issues.

Resubmitting a Paper Claim

When you resubmit an insurance claim, you submit the claim a second time.
Write “SECOND BILLING” in bold, red letters at the top of the copy you will send.
Resubmit the claim to the insurance company.

Usually, resubmitting a claim will at least get you more information about the
status of the original claim. The insurance company may have reimbursed the
patient directly and not notified you. If you resubmit the claim, the company will
send you an explanation of what action was taken on the original claim. Sometimes
the insurance company sends the patient notice of action on a claim, and the patient
ignores it. This leaves you and the provider in the dark. However, your second
submission will usually get you involved again and let you know if the patient was
paid directly or if the claim was denied. If the original claim was lost, then the
insurance company now has the copy of the claim and can process it.

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 Medical Coding and Billing Specialist

1500
SECOND BILLING
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
M F
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
Self Spouse Child Other

CITY STATE 8. PATIENT STATUS CITY STATE

Single Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
Employed
Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State) b. EMPLOYER’S NAME OR SCHOOL NAME
M F YES NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED DATE SIGNED

14. DATE OF CURRENT ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
INJURY (Accident) OR GIVE FIRST DATE
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

17b. NPI FROM TO

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. . 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
FROM TO PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
YES NO $ $ $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 33. BILLING PROVIDER INFO & PH #
DEGREES OR CREDENTIALS (I certify that the statements on the 32. SERVICE FACILITY LOCATION INFORMATION
reverse apply to this bill and are made a part thereof.)

SIGNED DATE a. b. a. b.

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Another reason to resubmit a claim is if you made a mistake with the original claim; if,
for example, you entered the wrong procedure code or perhaps had the policy number
wrong. To correct this, you should send the claim again, this time with the words
“SECOND BILLING—CORRECTION” at the top in red ink. This tells the insurance
company that it should ignore the first claim and use this new claim to process.

Electronic resubmittals are handled similarly.

Resubmitting an Electronic Claim

When submitting claims electronically, for example through a clearinghouse,
there are usually fewer instances when you must resubmit a claim due to errors.
Clearinghouse software edits claims, which identifies errors, such as incorrect codes
and missing information. This way you have the opportunity to correct these errors
and supply missing information before the claim is sent to the insurance company.

However, there will still be situations when an insurance company will require
additional information, such as accident information or a copy of a medical record,
in order to process the claim. You can simply resubmit the claim, along with
the attached information, electronically. Or in some cases, the health insurance
company will request a paper resubmittal so that you can indicate that the claim is a
second billing.

Also, electronic billing almost always results in an acknowledgement report of some

type. For instance, clearinghouses provide a list of received claims, each with a
tracking number that can be used should someone need to trace a claim.

Sending a Tracer
Just as its name implies, a tracer is a form that enables insurance companies
to locate a missing claim. The tracer contains billing information such as the
patient’s name, insured’s name, identification number and plan number. When
you submit a tracer, it lets the insurance company know there has been a problem
with a particular claim. The company takes the information from the tracer and
uses it to search for the claim. After the claim is found, the provider is notified and
informed of any action taken.

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Medical Coding and Billing Specialist

CLAIM TRACER FORM

Date ____________________

Insurance carrier name ___________________________________________________________________

Address _________________________________________________________________________________

Patient name ____________________________________________________________________________

Insured’s name ___________________________________________________________________________

Policy number ____________________________________________________________________________

Group name/number ______________________________________________________________________

Date of original claim submission ______________________ Amount __________________________

An excessive amount of time has passed since submission of our original claim as described above.
We have not received a request for additional information or payment on this claim. Please review
the attached copy of the claim and process for payment within seven days.

If there is any difficulty with this claim, please complete one of the items below and return this
letter to our office.

Claim pending because ____________________________________________________________________

Payment of claim in process ___________________ Date ____________________

Payment made on claim __________________

To whom ______________________________ Date ____________________

Claim denied _________________________________ Reason __________________________________

Additional remarks _______________________________________________________________________

__________________________________________________________________________________________

Thank you for your assistance in this important matter. Please contact our office if you have any
questions regarding this claim.

The office of (physician’s name), MD

Address __________________________________________________________________________________

Phone ___________________________________

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Filing a Narrative Explanation

Occasionally the insurance company might ask for a narrative explanation, which
is further explanation of procedures, diagnoses or other information on a claim. This
additional information is usually required for evaluation purposes as the insurance
company tries to decide if a claim is covered. In order to fulfill this request, you
should simply write out a detailed description of the items the insurance company
is questioning. On this narrative, you should include the patient’s name, insured’s
name, policy number and claim number at the top and then complete the description
below that information.

To create a narrative explanation, simply write out a detailed description

of the items the insurance company is questioning.

Remember, if an insurance company denies a claim, you should bill the patient directly.

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Appeals
Sometimes you might have to appeal an insurance company’s decision regarding
benefits. If you feel the insurance company’s ruling is wrong, you must complete
an appeals letter. An appeals letter is a document that spells out the claim filed,
the action taken and why you consider the reimbursement to be incorrect. When
completing an appeals letter, take into account all the information involved with the
claim and use it to dispute the insurance company’s action. The provider will provide
you with the reason or reasons the reimbursement is incorrect. Be sure to use that
information on the appeals letter. When submitting an appeal, address the letter to
your contact person in the insurance company.

When you appeal an action by Medicaid, you have between 30 and 60 days from
receipt of the denial to file the appeal, depending on the state. Appeals should
include a cover letter and copies of the original claim form, any preauthorization
forms and the explanation of benefits received. First, the regional fiscal intermediary
reviews appeals, and then the Department of Welfare. At each level, an examiner
reviews the case and makes a decision.

When you appeal an action by Medicare, you must do so within 60 days of the date you
received the notice of denial. Unless you can prove otherwise, Medicare deems that
you received the denial notice five days after the date on it. If you should need more
than 60 days to file the appeal, you can request more time from the intermediary at
the Medicare office. You will be notified in writing of the time granted you.

For TRICARE or CHAMPVA, if a claim is denied or returned by the claims processor

requesting additional information, or if you wish to appeal a decision, resubmit
the claim within 90 days of the notice. If you should need more time to correctly
resubmit or provide the additional requested information, you must contact the
claims processor for your area that is noted on the document you received and
request an extension of time.

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Here is an example of an appeals letter.

Doctor/Practice Name
Address
City, State ZIP code

Date (Very Important)

Insurance Company
Address
City, State ZIP code

Dear (Contact):

Our office recently received reimbursement for $ (insert amount) for (insert patient’s
name) for services on (insert date).

As you can see from the enclosed copy of the Explanation of Benefits, reimbursement
was reduced for this claim because the services were found to be (insert reason noted
on EOB).

Please review the services provided for (patient’s name). (The physician will
provide you with a short sentence that you should include here explaining the
necessity of treatment.)

Thank you for your attention to this request.

Sincerely,

Your name
Enclosed: EOB
Original claim

Usually, resubmitting a claim, sending a tracer or filing a narrative explanation is enough

to solve most problems with insurance companies. However, sometimes you need to do
more. You might have to utilize the state insurance commissioner or the court system.

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Medical Coding and Billing Specialist

The Insurance Commissioner

Insurance companies are governed by state regulations in all 50 states. Each state
has different requirements for insurance carriers, and each carrier must meet these
requirements to operate in that state. Even though a company might be based in New York,
in order to insure clients in Colorado, it must meet the requirements not only for New York,
but also for Colorado. This applies to every state where the company operates. An insurance
company is considered to be operating in a state if it issues any policies covering people in
that state. The regulations for insurance operations are overseen by the state insurance
commissioner—an official who reviews insurance companies and the companies’ business
habits and policy language to determine if they may operate in that particular state. The
commissioner also helps solve disputes involving insurance companies.

If you have a problem with an insurance company that cannot be solved through
normal channels (resubmission, tracer, narrative or appeals), you should contact the
insurance commissioner in your state to discuss it. Sometimes the commissioner will
step in and mediate the dispute, enabling both sides to come to an agreement.

Another reason to contact the insurance commissioner is if you suspect an insurance

company is operating illegally. Fraudulent claims, arbitrary denial of benefits, policy
cancellations and other actions have all been cause for insurance commissioner
investigations. To contact the commissioner in your state, look in the government
section of your phone book, usually under “Insurance Commission” or a similar listing.

Once in a while, you might have to go even beyond the insurance commissioner and use
the court system to settle a dispute with an insurance company. Court cases can be costly
and time consuming, so such disputes are usually large, involving a life-or-death situation
or, perhaps, a great sum of money. Court cases occur most frequently when a dispute
arises over the terms set forth in a policy rather than a simple billing inquiry or error.

Rejected Versus Denied Claims

As we discuss the medical bill process, it’s important to understand the difference
between a denial and a rejection of a claim.

Rejected claims (also called unprocessable claims) are either returned to the provider with an
explanation of the rejection or unprocessability or an explanation of this is sent without the
returned claim before any type of coverage determination is made. As you learned, incorrect
policy numbers, patient birth dates or sending the claim to the wrong insurance company
cause rejections. Once you resubmit the information, rejections are usually resolved.

Denials occur when the health insurance company receives and processes a claim,
but determines that the treatment in question isn’t a covered benefit in the plan.
When claims are denied, the provider is informed with the explanation of benefits
and/or denial letter. The letter includes denial codes that include a message like
“service not a benefit in enrollee’s plan,” “denied for lack of medical necessity” or
“denied coverage of experimental treatment.” Denials can be appealed if a mistake
has been made, and some denied claims are overturned.

You’ve explored various insurance problems in this section, and now it’s time to
apply what you learned. Let’s complete a quick Practice Exercise before we move on.

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 Step 5 Practice Exercise 21-1

 Match the term to the correct definition or description.

1. _____ Inquiry a. Sending in a claim a second

time with “SECOND BILLING”
2. _____ Resubmission written at the top
b. Oversees the state
3. _____ Narrative explanation insurance regulations
c. Asking an insurance company
4. _____ State insurance commissioner about a delayed claim
d. A further description of a procedure
or other information on a claim

 Step 6 Review Practice Exercise 21-1

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 7 Billing Patients

 Another responsibility of the coding and billing specialist is to bill patients. There
are different reasons why a patient may be billed. One reason is that the patient
does not have insurance and did not pay in full at the time of service. This would
generate a monthly bill to the patient. Another reason may be that a patient does
have insurance, but there is a deductible or portion still owed by the patient after
the carrier has reimbursed its portion of the claim.

Providers often divide their bills into cycles. There are several common billing
methods. Depending on the size of the practice, the patients may be divided using
the alphabet. For instance, Cycle 1 includes patients with the last names beginning
with the letters A through F. Cycle 1 patients are billed the first week of every
month. Cycle 2 includes patients with last names beginning with G through L and
bills are generated for these patients the second week of the month. And so on with
two more cycles to cover patients whose last names begin with M through Z.

Another billing method is event billing. Event billing generates a bill every time
something on the account is activated. For instance, when a patient has an office
visit, a bill is triggered. Or if the insurance company paid a portion of a patient’s
claim, a bill is generated to the patient for the remaining account balance.

It is important to have some kind of system to follow up on patients who have outstanding
balances. When an account slips through the cracks, it can be very costly to the provider.

Along with billing comes collection. With this in mind, you need to be familiar with
credit and collection concepts. Let’s discuss those concepts now.

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Medical Coding and Billing Specialist

 Step 8 Credit
 If you choose to run your own medical coding and billing service, you will be an
independent business person. You will deal with money every day. To understand
the financial world, you should know about two very important and common
concepts: credit and collection. Let’s go over the ins and outs of credit, including both
the lender side of the credit picture and the debtor side.

Let’s say you walk into a local department store and pick out a nice outfit. The clerk at
the register inquires about how you intend to pay for your purchase. “Will this be cash
or charge?” the clerk asks. You pull out your credit card and hand it to the clerk. You
have just charged your purchase and used credit.

When you receive goods or services in exchange for a promise to pay later, you
have used credit. Credit is the merchant’s acceptance of your promise to pay later
for goods or services you receive immediately. Some people may think credit is
only extended by large companies—companies or banks that issue credit cards, for
example. The real case, however, is much different. Many small, local stores issue
credit to people. The local hardware store might have credit accounts for contractors.
The office supply store might extend credit to local businesses.

Billions of dollars are charged every year. In one form or another, credit is issued not
only by the largest department store in New York City but also by the little mom-
and-pop shop in the smallest town. You might have a credit card issued by a bank.
Or perhaps you use department store or gasoline credit cards. In any case, if you are
operating an independent medical coding and billing service, you will need to decide if
you will extend credit and, if you do, to whom.

The person or business who issues the credit is called the creditor. The person or
business that receives the credit is called the debtor. Creditors and debtors often set
out the terms that the credit will follow. These terms, called a credit agreement,
include method and amount of payment, payment due dates and consequences
for missed payments or other problems, as well as procedures for canceling the
agreement. The credit agreement is very important for both the creditor and debtor
because it sets the terms for the repayment of the debt.

Right now, you probably are on the debtor side of most credit agreements. However,
that might not always be the case. You might allow providers to pay monthly for the
medical claims you file. Each week, you submit the claims, but because you extend
the provider credit, you do not require him to pay immediately. Instead, you send
him an invoice at the end of the month listing the total amount he needs to pay. This
makes you a creditor.

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Your Credit Report

Credit is a large part of everyone’s life—at least, nearly everyone. You use credit.
Your neighbors use credit. Your parents and friends use credit. You use credit for
the car and appliances you buy as well as the house you live in. If you have charged
goods or services, used a credit card or bought a car through a loan from a finance
company, you have a credit history.

Your credit history, called your credit report, lists all your credit accounts and
your payment history with those accounts. There are three agencies that compile
and keep credit reports—TransUnion, Experian and Equifax. Every time you apply
for credit, whether it is a new bank card, a department store credit card or an
automobile loan, the creditor will pull your credit report. This means the company
considering whether or not to loan you the money you requested will review a copy of
your credit report.

The credit report will tell the company how much money you owe and your history
regarding debt repayment. It is important to keep your credit report clean. This means
paying your bills on time. You might not think it matters if a bill is 10 days late.
However, the company you paid late might report that information to the agencies
that keep your credit report, and that information is attached to your report for a
minimum of three years. Information such as late payments, bankruptcies or defaults
is called negative credit information.

How can a potential creditor tell from your credit report how you made your
payments? That is a simple procedure. The creditor pulls your report and looks
at it. Usually, the report will list each credit account you have, and then under
each account, your payment history will appear. The report uses codes to indicate
payments. An A can mean you made that payment on time. A B means the payment
was 10-29 days late. A C means the payment was 30-59 days late. An X means you
missed the payment completely. (These abbreviations are meant for illustration only.
The actual code used on your credit report might be different.)

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Medical Coding and Billing Specialist

Let’s look at an example.

Both Harry Anyone and Lynn Nobody want to buy

a new car. They have been at their jobs for the same
CREDIT REPORT amount of time. They make about the same amount
Harry Anyone
of money a month. However, when the staff at the
123 Anystreet
automobile finance company look at Harry’s and Lynn’s
Anytown, US 00001 credit reports, they see the following.
Credit Accounts:
If you interpret the A codes to mean on time and the B
AnyBank Credit Card codes to mean late, which person do you think is more
Amount owed: ----------------- $3,000
likely to have a loan approved—Harry or Lynn? Harry
Payment history would have a much easier time, don’t you think? This
(the last 36 months) --- Last month is why it is so important to have a clean credit record.
If you strive to keep it clean by making payments on
AAAAABAAAAAAAAAAAAAAAA time, you will find it is easier to get credit.
AAAAAAAAAAAAAA
If your credit is not clean, do not give up hope. Finance
companies do not usually reject people with less than
CREDIT REPORT perfect credit records. These people, referred to as
Lynn Nobody credit risks, end up paying higher interest rates and, in
123 Nostreet some cases, making larger down payments.
Nowhere, US 00002
You are entitled to see your credit report. In fact, you
Credit Accounts: can request one free copy every year from the three
NoBank Credit Card credit reporting agencies—Experian, Equifax and
Amount owed: ----------------- $3,000 TransUnion. Search the Internet for the address of
each agency. As a rule, you should pull and review
Payment history your credit report every year to make sure there are no
(the last 36 months) --- Last month errors. It has been estimated that 75 percent of credit
reports contain at least one error. If there is an error,
AABBBBBAAAAAAABAAXAABAA
ABBAABBBBAABA
you need to write to the credit agency and request proof
of the debt shown. If the agency cannot prove you are
responsible for the debt listed, it must remove it from
the credit report.

When you have your own business, a clean credit

history can help you secure the financing you need for
new equipment (office furniture, computers, etc.).

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 Step 9 Delinquent Accounts

 Dr. John Randolph uses your medical coding and billing service and pays you with
a company check. However, when you deposit the check in your account, your bank
sends it back to you marked “Insufficient Funds.”

Louise Baker also uses your medical coding and billing service. However, for the
past two months, you haven’t received any payment for your services.

Look at the two examples. Which account, John’s or Louise’s, would you consider
delinquent? The answer is that both accounts are delinquent. A delinquent
account is any account in which the debtor has failed to live up to the credit
agreement. John paid with a check that did not clear his bank, so he failed to make
his payment. Right now, his account is just as delinquent as it would be if he hadn’t
made any payment at all.

Louise’s account is a little different. She has made no attempt to make a payment on
her credit account with your business. How should you handle these two situations?
Well, let’s look at John’s bad check first, then move on to Louise’s nonpayment.

Handling Returned Checks

The next time you shop, look around at the cash registers. You probably will see signs
that state some variation of: “There will be a charge for all returned checks.” This sign
warns people who write checks that, in addition to the amount on the check, the store
will collect an extra $20 for each check that is returned by the bank.

When a check is returned, it means that, for some reason, the bank the check was
drawn on has refused to honor it. Any time a check is returned, the merchant loses
the amount of money the check was written for. Say, for example, that Yancy’s Bait
Shop goes to deposit the day’s money. Included in the deposit is $400 cash and a
check for $45. The check gets returned by the bank. Instead of a deposit totaling
$445, Yancy’s Bait Shop is credited with only $400. You can imagine how returned
checks can cause havoc with a business. Why would a bank return a check? There
are several reasons.

To solve a problem with a client who has paid with a check that does not clear,
you should probably begin by contacting the client directly to arrange to receive
payment. You can also try to redeposit the returned check and hope there is enough
money in the bank to cover it. If all else fails, you can send the check to a collection
agency or file a court action.

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Reasons Banks Return Checks

1. If a bank returns a check for insufficient or nonsufficient funds, it means there is

not enough money in the checking account to cover the amount of money
on the check. Usually the letters NSF are stamped across the check. When the
bank returns a check for nonsufficient funds, that check has “bounced.”

2. Another reason a bank returns a check to a business is if the account is

closed. Obviously, if an account has been closed, a person should not be
writing checks on that account. The bank will not honor any such check.

3. A bank may return a check if the account holder stops payment on the
check, which means the account holder tells the bank specifically not to
honor a certain check. This process costs the account holder money and
is usually reserved for disputes between the check writer and the business.
An account holder who suspects a check has been stolen can use the stop
payment option to make sure that check does not clear. When a check
does not clear an account, no money is taken out of that account to cover
that check.

4. Finally, a bank will not honor a check if the check is filled out incorrectly or
illegibly. For example, if the numerical amount does not match the written out
amount, if the signature appears altered or forged, or if the account number
has been changed, the bank can refuse to honor the check.

Handling Nonpayment
Remember how Louise had ignored her bill and just did not paid at all? This can be
a problem, obviously, for you and your business. Without compensation, you might
quickly run out of money. How, then, can you go about collecting from Louise? The
first course of action is to send a friendly reminder. Think of your own experience.
If you’ve misplaced a bill, a simple “Have you forgotten?” letter reminds you to send
payment. Such a letter from you should read something like this:

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Dear Louise Baker:

Have our letters crossed in the mail? I am waiting for your

payment for my services in June and July. I value your business
and am looking forward to working with you more in the
upcoming months. If you have not sent out your payment of
_________, would you please do so now?

Thank you very much.

This first letter is to the point, but friendly. It simply reminds Louise that she hasn’t
paid you yet. It makes no threats. And it gives her an “out” by raising the possibility
that she has already sent the payment. Money is a sensitive subject. People can
become very embarrassed if they have to admit they haven’t paid their bills. Don’t
press your delinquent clients too far in the first letter.

However, if another two weeks go by and you still haven’t been paid, send a second letter.
This one should be a little more serious and should list a consequence for nonpayment.

Dear Louise Baker:

In reviewing my bills, I noticed your account is more than two

months past due. I hope you received my first reminder. This is
your second notice in the past two weeks. If there is a problem
with my invoice or services, please contact me immediately, and
I’m sure we can work things out.

I must stress to you that I need to receive your payment

of _________ by (fill in date two weeks from today), or I will
be forced to take the next step in my effort to collect. This
step can include a collection agency and, as per our contract,
significant additional cost to you.

If you have already sent your payment, thank you very much.

You see, this second notice sounds more threatening than the first, but still doesn’t
go overboard and beat Louise over the head. She now knows exactly what she owes,
what to do if she has a problem and what will happen if she doesn’t pay her bill.

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After two more weeks, if you still haven’t received payment, then you should take
the next step in the collection process. That next step could be either a collection
agency or a court action.

 Step 10 Collection Agencies

 Look back at the example of Louise’s account. Let’s say you have tried to contact her,
but have not received any payment. Her account is now three months overdue, and
she has made no effort to explain why. In cases such as this, you might be forced
to take more drastic steps beyond cutting off your service to her and sending her
letters. You might need to pass her account on to a collection agency.

Using Collection Agencies

Collection agencies are businesses that specialize in collecting unpaid debts for
other businesses. Usually these agencies are under contract to handle the delinquent
accounts of a variety of businesses. Collection agencies, and the collection agents
they employ, handle all the contact, follow-up and other financial arrangements for a
business’s delinquent accounts.

Although the use of a collection agency might seem to be an ideal arrangement for
a business that has delinquent accounts, it isn’t always so terrific. You see, in order
to perform their services, collection agents collect a commission for every delinquent
account they settle. Ordinarily, this commission comes out of the total debt owed to
the business. In the contract with a collection agency, the business agrees to give up
a certain percentage of the amount owed if the collection agency is successful. This
percentage can be as high as 50 percent. That means if you turn Louise’s delinquent
account over to a collection agency, you can expect to receive only half of what she
owes you. The other half goes to the collection agency, to pay for its services. If
Louise owes you $500, you would ultimately receive only $250—if the agency is
successful in collecting at all.

Even collection agencies can have some

problems collecting. Often the collection
agent contacts the debtor and arranges for
that person or business to make monthly
payments. Sometimes this arrangement
works and sometimes it doesn’t.

When nothing seems to work, the

collection agency might choose to file a
court action against the debtor. You can
also file a court action if you do not wish
to use a collection agency. Small claims Collection agencies specialize in
court can be a very effective method of collecting unpaid debts.
recouping debts.

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 Step 11 Small Claims Court

 In the United States, each state has a small claims court designed for parties to
settle disputes without attorneys. Each state has its own rules for small claims
court. These rules include the maximum dollar amount you can sue for, the
method you must use to notify the other party (the defendant) and the procedures
you must follow to file a valid claim.

Filing a Claim
Filing a claim usually requires a filing fee (most likely, less than $100). Then you
must serve the person you are filing against—the defendant. The person filing the
action, or suing the defendant, is called the plaintiff. Both the plaintiff and the
defendant are said to be parties in the lawsuit.

Most states require you to have a responsible person hand-deliver the notice of the
court action to the defendant, called serving the defendant. Mailing the notice is
not acceptable in most states. After the defendant has been served, you both appear
in court on the set date and present your sides of the case. If either party fails to
appear, the person who does appear is awarded a default judgment. Basically, a
default judgment means the person who appears wins. If the defendant wins, then
the lawsuit is dismissed. If the plaintiff wins, the judge orders the defendant to pay
compensation to the plaintiff.

Let’s say you decide to take Louise to court. You file the court action with the county
clerk and then have Louise properly served. The court date is September 21. On
September 21, you arrive in court and Louise is there. You both present your sides
of the case. The judge rules that Louise owes you the money and must pay. You have
won the case. The judge then enters a judgment in your favor on the court records.
This judgment shows how much you are owed and when the court case took place.
But how do you collect? We will cover that question in the next section.

If you lose a small claims court action, you usually cannot take any further action.
Also, any person who is served with a small claims court summons can choose
to “bump” the case up to county court, where attorneys are permitted. This can
increase your costs, so be sure of your case.

Collection agencies usually file in county court and use an attorney to collect
delinquent debts. Even if the agency wins, you still will only see about 50 percent of
the original debt.

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Collecting a Judgment
Once you win a court case, you do not necessarily collect your money right then and
there. The court case gives you a judgment. This judgment is your ammunition in
your fight to collect. Depending on your state, you can use the judgment to collect
part of the defendant’s paycheck. Or you might be able to force the defendant to sell
personal property to pay the judgment. In any case, you must take the judgment a
step beyond the courtroom to collect money.

If your state permits, you can use the judgment to get an order of garnishment. An order
of garnishment is a legal document requiring the defendant’s employer to withhold a
percentage of the defendant’s pay each month and send that money to you. This goes on
as long as the defendant owes money on the judgment and works for that employer. Each
time the defendant changes employers, you must get a new order of garnishment.

 Step 12 Solving Patient Problems

 If you work in a medical office, typically you deal with patients. This means that
you see them on good days when they’re happy and on bad days when something is
wrong. Sometimes the patient feels fine physically, but has some serious concerns
regarding the bill. Imagine this common scenario:

Rosita Perez had surgery a month ago and saw the doctor two weeks ago for a follow-
up examination. Today she comes into the office waving a bill around. When you try
to talk to her, she breaks in.

“Why are you sending me this? My insurance

company should have paid it!” she exclaims.

Now, you know that your billing software

automatically prints bills for accounts that
have outstanding balances. This bill is sent to
the responsible party listed for the account.
In Rosita’s case, her insurance company has
been billed, but hasn’t paid yet, so the bill
was generated and sent to Rosita. You need to
explain this to her. How should you approach
When handling an upset patient, remain calm.
the subject? Remember, Rosita is currently very
upset because she has just opened a bill that she
hadn’t counted on receiving, and we all know
how stressful that can be.

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The first thing you need to do is remain calm! If you allow yourself to become
agitated, all you have accomplished is to create a completely unworkable situation.
If you stay calm, you can work first on calming down Rosita, and then you can
move on into the explanation of the bill. You need to keep in mind that most people
don’t understand how the whole billing process works. You, as a medical coding
and billing specialist, understand the process and you need to explain it, briefly, to
troubled patients.

With this in mind, you should be prepared to weather a small storm as agitated
patients vent their frustration. (This should never, however, become an assault on
you—after all, the patient is not mad at you; she is mad at the bill.) If the venting
becomes personal, you should gently guide the conversation elsewhere.

1. Take control of the situation by asking to see the bill. Once you have the bill, look
it over and confirm the situation. Usually, a patient will give you the chance to
look at the bill. If the patient won’t, explain that you cannot help unless you see
the item of concern. Always approach the situation from a “how can I help you”
point of view. Be on the patient’s side.
2. Once you have the patient’s attention, explain the specific situation. In Rosita’s
case, you explain that the insurance company has been billed, but has not paid
yet. This leads the computer to produce and send out a bill to the patient. Rosita
shouldn’t worry about the bill until she is contacted by the doctor’s office and
told exactly what the insurance company did and did not cover. Any portion of
the bill remaining after the insurance company reimbursement is received is the
patient’s responsibility, unless, of course, the provider is a preferred provider, in
which case the provider will write off any unpaid amount.
3. If patients have questions about their specific insurance policies, refer them to
their insurance representatives or agents. You cannot possibly know everything
about every patient’s coverage, although some patients might think you are
responsible for their insurance companies denying their claims.
4. When an insurance company has paid, but the patient believes the reimbursement
is too low, step in and see if you can help. Again, be on the patient’s side. Ask if you
can call the insurance company for the patient to check the explanation of benefits.
Then get in touch with your insurance contact and ask.
Overall, the most important thing to remember when dealing with anxious patients
is to be on their side. Be an advocate, not an adversary. If you set yourself up as the
“knight in shining armor,” the patient will look on you as an ally, not someone to be
yelled at. Because you have been trained to deal with insurance companies, you are
better suited to ask questions about specific claims. Use this knowledge to help out
patients who have questions and are worried about bills they thought were covered.

Insurance companies and patients are not the only potential trouble sources. You
might, from time to time, encounter a problem with a provider.

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 Step 13 Solving Problems With Providers

 Doctors are human beings, as are medical coding and billing specialists. Human
beings occasionally have misunderstandings or conflicting attitudes. When you run
into such a problem with a provider, you must take a page from your solving-patient-
problems book and stay calm. No matter what the problem, a screaming match won’t
solve anything. It is amazing how quickly an intelligent discussion can deteriorate
into a match of volume if the two parties allow it. However, if you stay calm, you can
more effectively deal with any problem because you present a professional image.

If the doctor has a problem with something you’re doing, stop. If you have a question
about why what you’re doing is wrong, ask it. You need to know. If you are performing
a necessary task, explain why it is important. In any case, listen to what the doctor is
saying. Sometimes you might have to accept the doctor’s instruction, regardless of how
you feel about it. After all, whether you are an outside coding and billing specialist or
an in-house employee, it is likely that you work for the provider. Both sides may have
to compromise. This constant give-and-take enables both the provider and the coding
and billing specialist to be comfortable with the working environment.

What would you do if a provider asked you to do something fraudulent? Let’s look at
Jason, a medical coding and billing specialist who works with Dr. King. One day when
she hands him a bill, Dr. King says, “Don’t use the surgical package code. I never do
because we’ll get more money if we code everything separately.” If Jason does as Dr.
King suggests, he will commit fraud. Jason knows this, and explains to Dr. King that
he’s not comfortable coding things separately—after all, his job is to code accurately.
Jason goes on to say that he’s liable if he knowingly submits fraudulent claims. Dr.
King says she respects his integrity, and thanks him for saying something because she
didn’t realize that coding to receive more money was fraudulent.

Another key to a professional attitude is to acknowledge your mistakes. If you forgot to file a
claim, don’t shrug off responsibility by claiming it was misplaced by the insurance company.
It is important for the provider to know you are trustworthy. If you do not take responsibility
for your actions, including those that are wrong, you lessen your own credibility.

In addition to taking responsibility, be prepared to solve problems. If something needs

to be done and you can do it (and you have time), volunteer to do it. Make yourself
valuable to the office and to the doctor.

 Step 14 Professional Liability Insurance

 When you begin your career as a professional medical coding and billing specialist,
you might be a self-employed contractor with a doctor’s office or healthcare
facility. Or you might work as an employee for a doctor or an outpatient facility.
Whatever the case, you will be responsible for many decisions related to medical
codes. Because of this, you are partially responsible for financial reimbursement
for medical services provided to patients. Although it’s not an everyday event, in
today’s medical environment of high costs and frequent lawsuits, an unintentional
but significant error in your work could put you at risk for malpractice.

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This is not meant to scare you. Unfortunately however, lawsuits are a growing trend
in many professions today. Healthcare professionals and medical coding and billing
specialists are no exception. The best defense against a lawsuit is being properly
trained and having professional liability insurance. You’ve taken the right step on
the education front, so let’s focus on liability.

Professional liability insurance is just what it sounds like. It’s

insurance to protect you if anyone decides to sue you for malpractice.
In terms of coding and billing, this might be because of some coding or
billing error. If you are sued, professional liability insurance typically
pays for legal fees, court costs, court judgments and even out-of-court
settlements. As those who have been sued for medical malpractice
will tell you, the investment in liability insurance is worth the cost
for the security and peace of mind it provides. Understand that if you
are an employee, your employer should already have insurance. You
won’t need to worry about being protected. However, if you decided to Professional liability
form your own coding and billing business, you would need to arrange insurance is a wise
for your own liability insurance. investment for
self-employed coders.

 Step 15 How Does Compliance Affect Medical

Coders and Billers?
 We’ve briefly discussed compliance throughout your course, but you’re probably wondering
what it actually means. Well, compliance means making sure that your company or
facility provides and bills for services according to the regulations, laws and guidelines
that govern it. The correct handling of medical records is vitally important to compliance.

Elements of Compliance
In addition to following the guidelines given in this lesson, a company or facility must
protect itself from the risk of prosecution and keep itself on course. The provider or office
manager typically creates a compliance plan, and the medical coding and billing specialist
follows the plan. Creating a compliance plan involves developing standards of conduct,
education, auditing, monitoring and developing and updating a plan of conduct all are
essential elements of compliance. Specifically, the plan should include statements that
address current reimbursement, claims submission and proper documentation of services.

Essential Elements of Compliance

A plan for compliance should ensure the following:

1. The services billed are accurate and properly documented.

2. Marginal notes or late entries in the medical record must be noted and explained.
3. All bills follow current coding procedures and regulations.
4. Correct and appropriate documentation exists for DRG coding, Medicare Part B
and patient discharges.

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Compliance means not only abiding by the rules and regulations that govern your
company or facility but also documenting proof that you are abiding by these rules
and regulations. Some other areas that are expected to be included in compliance
plans are:

5. Patient confidentiality/release of information

6. Human resources
7. Infection control
8. Plant safety and waste management
9. Marketing
10. Patient dumping
11. Admission and discharge policies
12. Medical necessity of services provided
13. Patient recruiting techniques
Yearly compliance training programs are necessary for all employees. These
educational programs should include corporate ethics, coding and billing procedure,
ethical marketing techniques, fraud and abuse laws, and ethical management styles.
Coders, billers and coding managers are in a position to put the company or facility
at risk and should be educated regularly on the following topics:
 Medicare reimbursement principles

 Billing Medicaid and Medicare for services not rendered

 Misrepresentations of the nature of services rendered

 Alterations of medical records

 Billing in violation of the Medicaid/Medicare bundling regulations

 Violating patient transfer policies

It’s also a good idea to become familiar with the major investigative targets
of government regulating agencies. Good sources of information about fraud
investigations include the annual work plan of the Department of Health and
Human Services or HHS, fraud alerts issued by the Office of Inspector General
or OIG, and medical reviews in fiscal intermediaries’ provider newsletters.

In all settlement agreements to date, the OIG requires an outside agency to audit
coding and billing practices annually. Coding audits can be conducted as frequently
as monthly, but they should definitely be validated annually.

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Though extensive written policies on compliance sometimes gather dust in the

employee lounge, it is important to take the time to carefully document policies
and procedures. The documents act as references for staff members who never
were trained on certain issues or who may not remember the training they had.
The actual writing process helps improve current practices, as each step must be
examined as it’s documented. Also, written procedures help distribute important
information in situations where a supervisor or manager is not available. It is
always easier to follow the rules if you know what they are and if you understand
the consequences for not following them.

Now, let’s review what you’ve learned with a Practice Exercise.

 Step 16 Practice Exercise 21-2

 Complete each sentence below by determining the correct word(s) or phrase.

1. ___________________________ is the merchant’s acceptance of your promise

to pay later for goods or services you receive immediately.

2. The document listing your credit history is called your credit ________________.

3. The document listing your credit history is important to potential

___________________________________ who are considering giving you credit.

4. Late payments, bankruptcies and defaults are called ________________________

___________________________________________________________________________.

5. People referred to as credit risks end up paying _______________________

interest rates.

6. If a debtor fails to live up to his credit agreement, his account

is ________________________________.

7. If a check bounces, the bank returns the check with the letters
_______________________________ stamped across the check.

8. The person filing the action in small claims court is the _____________________.

9. The person being sued in small claims court is the ________________________.

10. The defendant’s employer withholds a percentage of the defendant’s pay

each month and sends the money to the creditor. In order to do this, a
legal document called a(n) ________________________________________________
is required.

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Medical Coding and Billing Specialist

 Step 17 Review Practice Exercise 21-2

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 18 Lesson Summary

 If you run into problems with an insurance company, go through your regional
representative first, using inquiries, narrative explanations and the resubmission of bills
to solve problems. If necessary, you can go through your state’s insurance commissioner to
help solve problems. The court system is also available, but that is usually a last resort.

This lesson also illustrates just how important credit is today in the United States.
Virtually everyone has used credit in some manner. Department stores, banks and
even small mom-and-pop businesses issue credit and charge goods. Your credit
rating is essential to any application for credit. The three credit reporting agencies
keep your entire credit history in a file that is released to potential creditors when
you apply for credit. You should look at your credit report at least once a year. These
reports, while mostly accurate, can contain errors and omissions.

If you ever run into a situation where a person or business owes you money, you
should first try to work out the problem yourself. Use friendly reminders and follow-
up letters. However, if those efforts fail, you might have to turn to the services of a
collection agency or even to the legal system.

When you deal with problems, how much you accomplish depends on how you
approach the situation. If you allow yourself to become agitated and angry, you won’t
accomplish much. However, if you remember to stay calm and take control of the
situation, you can solve problems quickly and effectively. When you deal with patients,
remember that they don’t know much about the billing process. Be prepared to explain
yourself more than once, and use language the patient understands.

Doctors are people, too. You might not care for the manner in which a doctor tells
you to do something, but you should stay calm and work through the problem.
Sometimes a compromise can be worked out; other times, you just have to complete
the task as the doctor instructs. In any case, approach all problems with a
professional attitude. This will enable you to be effective in dealing with whatever
problems the medical field throws at you.

Before completing the quiz for this lesson, take some time to review the sample
business forms that you may encounter as a medical coding and billing specialist.

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Business Forms for a Medical Coding and Billing Specialist

The medical coding and billing specialist is responsible for maintaining
confidentiality of privileged information. This is an example of a Business Associate
Agreement that may be used by an employer when she hires a medical coding and
billing specialist. ⎯

SAMPLE BUSINESS ASSOCIATE AGREEMENT

THIS BUSINESS ASSOCIATE AGREEMENT (“Agreement”) is entered into on this _____

day of _____________, 20__ (the “Effective Date”), between [your provider office] (“Covered
Entity”) and _____________________ (“Business Associate”) (each a “Party” and collectively
the “Parties”).

WHEREAS, Covered Entity will disclose and/or make available to Business Associate Protected
Health Information (“PHI”) in connection with services provided to Covered Entity by Business
Associate, which information is confidential and must be given special protection; and

WHEREAS, Business Associate will have access to and/or create on behalf of and/or receive
from Covered Entity Protected Health Information that can be used or disclosed only in
accordance with this Agreement and the HHS Privacy Standards Rule;

NOW, THEREFORE, the Parties hereby agree as follows:

1. DEFINITIONS.

1.1 Disclosure. Disclosure shall mean the release, transfer, provision of access to, or
divulging in any other manner of information outside the entity holding the information.

1.2 Health Care Operations. Health Care Operations shall have the meaning as set out in its
definition in 45 CFR § 164.501, as such provision is currently drafted and as it is subsequently
updated, amended, or revised.

1.3 HHS. HHS shall mean the Department of Health and Human Services.

1.4 HHS Privacy Standards Rule. HHS Privacy Standards Rule shall mean the Code of
Federal Regulations (“CFR”), Title 45, §§ 160 and 164, as such regulations are currently drafted
and as they are subsequently updated, amended, or revised.

1.5 Individual. Individual shall mean the person who is the subject of the Protected Health
Information and shall include a person who qualifies as a personal representative in accordance
with 45 CFR § 164.502(g).

1.6 Protected Health Information. Protected Health Information shall have the meaning as
set out in its definition in 45 CFR §164.501, as such provision is currently drafted and as it is
subsequently updated, amended, or revised.

1.7 Secretary. Secretary shall mean the Secretary of Health and Human Services or his/her
designated representatives.

1.8 Use. Use shall mean, with respect to individually identifiable health information,
the sharing, employment, application, utilization, examination, or analysis of such
information within an entity that maintains such information.

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2. PERMITTED USES AND DISCLOSURES OF PROTECTED HEALTH

INFORMATION.

[2.1 Permitted Uses and Disclosures. The Parties hereby agree that, except as otherwise
specified herein, Business Associate may make any and all uses and disclosures of PHI received
from, created on behalf of, and/or made available by Covered Entity for the following stated
purposes:
Here list the purposes for which PHI will be used, such as: to file health care
claims on behalf of Covered Entity; to properly track the status of such
claims; and to generate any necessary documentation for the above.]
or, if a separate services contract is in place,
[2.1 Permitted Uses and Disclosures. The Parties hereby agree that, except as otherwise
specified herein, Business Associate may make any and all uses and disclosures of PHI necessary
to perform its obligations under the [name of services agreement].]

3. USE AND DISCLOSURE OF PHI FOR MANAGEMENT, ADMINISTRATION,

AND LEGAL RESPONSIBILITIES.

3.1 Use. Notwithstanding the provisions of Section 2 above, Business Associate is permitted to
use the PHI in its possession if necessary for its proper management and administration or to fulfill
any present or future legal responsibilities of the Business Associate, provided that such uses are
permitted under applicable Federal and State confidentiality laws.

3.2 Disclosure. Notwithstanding the provisions of Section 2 above, Business Associate is

permitted to disclose the PHI in its possession to third parties if necessary for its proper management
and administration or to fulfill any present or future legal responsibilities of the Business Associate,
provided that the Business Associate represents to the Covered Entity in writing that (a) the
disclosures are required by law, as provided for in 45 CFR § 164.501 or (b)
the Business Associate has received from the third party written assurances regarding its confidential
handling of such PHI as required under 45 CFR § 164.504(e)(4).

4. OTHER PERMITTED USES AND DISCLOSURES.

4.1 Data Aggregation Services. Notwithstanding the provisions of Section 2 above, Business
Associate is permitted to use and/or disclose PHI to provide data aggregation services, as that term is
defined in 45 CFR § 164.501, relating to the Health Care Operations of Covered Entity.

5. RESPONSIBILITIES OF BUSINESS ASSOCIATE WITH RESPECT TO PHI.

5.1 Limits on Use and Disclosure. Business Associate hereby agrees that PHI created on behalf
of or provided or made available by Covered Entity shall not be further used or disclosed
by Business Associate other than as permitted or required by this Agreement or as otherwise
required by law. Except as permitted in Sections 3 and 4 above, Business Associate shall
not use or further disclose PHI in a manner that would violate the requirement of the HHS
Privacy Standards Rule if done by Covered Entity.

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⎯

5.2 Reports of Improper Use or Disclosure. Business Associate hereby agrees to report to
Covered Entity any use and/or disclosure of PHI that is not permitted or required by this
Agreement of which Business Associate becomes aware within __ days of Business Associate’s
discovery of such unauthorized use and/or disclosure.

5.3 Appropriate Safeguards. Business Associate will establish and maintain appropriate
safeguards to maintain the security of PHI and to prevent any use or disclosure of such PHI other
than as provided for by this Agreement.

5.4 Subcontractors and Agents. Business Associate hereby agrees that whenever PHI is
provided or made available to any of its subcontractors or agents as permitted by this Agreement,
Business Associate will require such subcontractors or agents to agree, in writing, to adhere to the
same terms, conditions, and restrictions on the use and/or disclosure of PHI that apply to Business
Associate pursuant to this Agreement.

5.5 Right of Access of an Individual. At the request of and in the time and manner
designated by Covered Entity, Business Associate hereby agrees to make available and provide a
right of access to PHI by Covered Entity or the Individual, in accordance with the provisions of
45 CFR § 164.524.

5.6 Amendments to PHI. At the request of and in the time and manner designated by
Covered Entity, Business Associate hereby agrees to make PHI available for amendment and to
incorporate any amendment(s) to PHI pursuant to 45 CFR § 164.526.

5.7 Accounting of Disclosures. (a) Business Associate agrees to document such disclosures
of PHI and information related to such disclosures as would be required for Covered Entity to
respond to a request by an Individual for an accounting of disclosures of PHI in accordance with
45 CFR § 164.508. (b) Within 45 days of receiving a written request from Covered Entity,
Business Associate hereby agrees to make such information available to Covered Entity as is
requested by Covered Entity to permit Covered Entity to respond to a request by an Individual for
an accounting of disclosures in accordance with 45 CFR § 164.528.

5.8 Access to Books and Records. Business Associate shall make available to the Secretary its
internal practices, books, and records relating to the use and disclosure of PHI received from, or
created or received by Business Associate on behalf of, Covered Entity for the purposes of
determining Covered Entity’s compliance with the Privacy Rule, in accordance with
45 CFR § 164.504(e)(2)(ii)(H).

6. RESPONSIBILITIES OF COVERED ENTITY WITH RESPECT TO PHI.

6.1 Change in Notice of Privacy Practices. Covered Entity agrees to inform Business
Associate of any changes in the form of the Notice of Privacy Practices that Covered Entity
provides to Individuals pursuant to 45 CFR § 164.520, and agrees to provide Business
Associate with a copy of the notice currently in use.

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6.2 Change or Withdrawal of Permission. Covered Entity agrees to inform Business

Associate of any changes in the form of, or revocation of, permission by an Individual to use or
disclose PHI, to the extent such changes may affect Business Associate’s use or disclosure of
PHI.

6.3 Changes in Requirements. Covered Entity agrees to notify Business Associate of any
arrangements permitted or required of Covered Entity under the HHS Privacy Standards Rule
that may impact in any manner the use and/or disclosure of PHI by the Business Associate under
this Agreement, including, but not limited to, restrictions on use and/or disclosure of PHI as
provided for in 45 CFR § 164.522 agreed to by Covered Entity.

6.4 Permissible Requests. Covered Entity shall not request Business Associate to use or
disclose PHI in any manner that would not be permissible under the HHS Privacy Standards
Rule if done by Covered Entity, except as provided in Sections 3 and 4 above.

7. TERM AND TERMINATION.

7.1 Term. This Agreement shall become effective on the Effective Date and shall continue
in effect until all obligations of the Parties have been met, unless terminated as provided in this
section.

7.2 Termination of Agreement. Pursuant to 45 CFR § 164.504(e)(2)(iii), Business

Associate agrees Covered Entity may immediately terminate this Agreement if Covered Entity
determines that Business Associate has violated a material term of this Agreement.
Alternatively, Covered Entity may choose to (a) provide Business Associate with __ days’
written notice of the existence of an alleged material violation, and (b) afford the Business
Associate an opportunity to cure said alleged material violation upon mutually agreeable terms.
If mutually agreeable terms cannot be reached within __ days, then Business Associate must
cure said violation within __ days to the satisfaction of Covered Entity. If Business Associate
fails to cure such violation as set forth in this paragraph, Covered Entity may immediately
terminate this Agreement. If neither termination nor cure are feasible, Covered Entity shall
report the violation to the Secretary.

7.3 Effect of Termination. Upon the termination of this Agreement, Business Associate
agrees to return or destroy or return all PHI received from, or created or received by Business
Associate on behalf of, Covered Entity that Business Associate or its subcontractors or agents
still maintain in any form, pursuant to 45 CFR § 164.504(e)(2)(ii)(I). Business Associate agrees
that it shall not retain any copies of such PHI. Alternatively, if such return or destruction of such
PHI is not feasible, then Business Associate agrees to extend the protections of this Agreement
to such PHI for as long as necessary and to limit further uses and disclosures to those purposes
that make the return or destruction of such PHI infeasible.

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 Solving Problems with Insurance Carriers, Providers and Patients
⎯

8. MISCELLANEOUS.

8.1 Governing Law. This Agreement shall be governed by the laws of the State of
.

8.2 Notice. Whenever under this Agreement one Party is required to give notice to the other,
such notice shall be deemed given if mailed by First Class United States mail or by express courier,
postage prepaid, to such Party’s address as given below, and/or via facsimile to the facsimile
telephone numbers listed below.

Business Associate: Covered Entity:

Attention: Attention:
Fax: Fax:

Each Party may at any time change its address and that of its representative for notice by
giving notice thereof in the manner provided above.

8.3 Headings. The headings of this Agreement are included for ease of reference only and
shall not enter into the interpretation of this Agreement.

8.4 Counterparts. This Agreement may be executed in any number of counterparts, each of
which shall be deemed to be an original. Facsimile copies of this Agreement shall be deemed
to be originals.

IN WITNESS WHEREOF, each of the undersigned has caused this Agreement to be duly
executed in its name and on its behalf effective as of ________________, 20__.

BUSINESS ASSOCIATE COVERED ENTITY

By: By:

Print name: Print name:

Print title: Print title:

Date: Date:

0205502LB03A-21-13 21-31
Medical Coding and Billing Specialist

This is an example of a provider’s signature authorization form that can be

completed, notarized and sent to the insurance carrier. This form allows insurance
claims to be processed with the use of a signature stamp. A copy is retained for the
medical coding and billing specialist and the physician’s records.

PROVIDER’S NOTARIZED FACSIMILE OR

STAMP SIGNATURE AUTHORIZATION

State of __________________________________)
) ss
County of ________________________________)

_________________________________________ being first duly sworn, deposes and

says: I hereby authorize the ____________________ (name of fiscal administrator) to
accept my facsimile or stamp signature shown below

______________________________________________
Facsimile or Stamp Signature

as my true signature for all purposes under the _________________________________

(name of insurance program) in the same manner as if it were my actual signature,
including my agreeing to abide by the full payment concept and the remainder of the
certification normally signed by the source of care as it appears on all claim forms.

______________________________________________
Signature

Subscribed and sworn to before me this _______________ day of __________ 20____.

_________________________
Notary Public

in and for ____________________ County, State of _________________________

(SEAL)
My Commission expires _________________

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 Solving Problems with Insurance Carriers, Providers and Patients

This is an example of a fax cover sheet that would be used when transmitting
patient information. It is used when transmitting claims data, when resubmitting
an unpaid insurance claim, to send further documentation on a claim to insurance
carriers or to obtain preauthorization for a patient. It is important to protect the
patient’s confidentiality. Documents containing sensitive information, such as
information on sexually transmitted diseases, drug or alcohol treatment or human
immunodeficiency virus, should not be faxed.

FAX COVER SHEET

Date: _________ Time: _________ Number of pages

(including cover sheet): ______

To: _____________________________ Fax number: _______________

From: ___________________________ Phone: ____________________

Fax number: ________________

This fax transmittal may contain information that is privileged, confidential and exempt
from disclosure under applicable law, and is intended only for the use of the identified
individual to whom it is addressed. If you have received this transmittal in error, please
notify this office immediately by telephone.
If you cannot read this fax, or if pages are missing, please contact this office by
telephone.

______________________________________________________________________

Instructions to the authorized receiver: Please complete this statement of receipt and
return to sender via the above fax number.

I, ____________________________________________________, verify that I have

received ____________ number of pages, including the cover sheet.

0205502LB03A-21-13 21-33
Medical Coding and Billing Specialist

Many insurance carriers will reimburse the patient directly unless otherwise noted
on the claim form. This is an example of an authorization form for payment of
insurance benefits to be paid directly to the physician. The authorization may be
a paragraph included on the encounter form or it may be a separate form that is
maintained in the patient’s medical chart. Below are examples of both.

CONSENT FOR PHYSICIAN REIMBURSEMENT

I request payment of insurance benefits either to myself or to the physician listed on this
claim.

___________________________________
Patient or Responsible Party signature

CONSENT FOR PHYSICIAN REIMBURSEMENT

I hereby authorize (insurance carrier’s name) to mail insurance benefit payments directly
to (physician’s name and address) for medical services received for the time period of
(specific dates).

___________________________________
Patient or Responsible Party signature

___________________________________
Relationship to patient

___________________________________
Date of signature

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 Solving Problems with Insurance Carriers, Providers and Patients

This is an example of a claim tracer form. This form should be submitted to the insurance
carrier with a copy of the original claim submitted for payment. The time limit for
receiving insurance reimbursement can vary depending on the insurance carrier.

CLAIM TRACER FORM

Date _____________________________
Insurance carrier name ____________________________________________________
Address ________________________________________________________________
Patient name ____________________________________________________________
Insured’s name __________________________________________________________
Policy number ___________________________________________________________
Group name/number ______________________________________________________
Date of original claim submission _____________ Amount ________________
An excessive amount of time has passed since submission of our original claim as described
above. We have not received a request for additional information or payment on this claim.
Please review the attached copy of the claim and process for payment within seven days.
If there is any difficulty with this claim, please complete one of the items below and return
this letter to our office.
Claim pending because ___________________________________________________
Payment of claim in process _______________ Date __________________
Payment made on claim ___________________
To whom __________________ Date __________________
Claim denied ___________________________ Reason ________________
______________________________________________________________________
Additional remarks ______________________________________________________
______________________________________________________________________
Thank you for your assistance in this important matter. Please contact our office if you have
any questions regarding this claim.
The office of (physician’s name), MD
Address _______________________________________________________________
Phone ___________________________________

0205502LB03A-21-13 21-35
Medical Coding and Billing Specialist

An appeals letter must accompany all requests for a review of the reimbursement received
for an insurance claim. This is an example of an appeals letter. Always attach a copy of
the original claim form and a copy of the EOB received from the insurance carrier.

Doctor/Practice Name
Address
City, 6tate =,3 code

Date Very ImportanW

Insurance Company
Address
City, 6tate =,3 code

Dear (Contact):

Our office recently received reimbursement for $ (insert amount) for (insert patient’s
name) for services on (insert date).

As you can see from the enclosed copy of the Explanation of Benefits, reimbursement
was reduced for this claim because the services were found to be (insert reason noted on
EOB).

Please review the services provided for (patient’s name). (The physician will provide
you with a short sentence that you should include here explaining the necessity of
treatment.)

Thank you for your attention to this request.

Sincerely,

Your name

Enclosed: EOB
Original claim

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 Solving Problems with Insurance Carriers, Providers and Patients

This is an example of a letter asking for the claim to be reviewed. This letter is
appropriate when the insurance carrier has denied the payment and after adequate
research, you believe there may be an error and that payment should have been
approved. Attach a copy of the original claim form and a copy of the EOB received
from the insurance carrier.

Doctor/Practice Name
Address
City, 6tate =,3 code

Date Very Important

Insurance Company
Address
City, 6tate =,3 code

Dear (Contact):

Our office recently received a denied claim for (insert patient’s name) for $ (insert
amount) for services on (insert date) from your insurance office.

As you can see from the enclosed copy of the Explanation of Benefits, this claim was
denied because (insert reason noted on EOB).

Please review the services provided for (patient’s name). (The physician will provide
you with a short sentence that you should include here explaining the necessity of
treatment.)

If you need additional information, please contact our office. Thank you for your
attention to this request.

Sincerely,

Your name

Enclosed: EOB
Original claim

0205502LB03A-21-13 21-37
Medical Coding and Billing Specialist

When a workers’ compensation claim becomes 45 days delinquent, a letter should be

sent to the insurance carrier. Below is a sample of such a letter.

Doctor/Practice Name
Address
City, 6tate =,3 code

Date

Insurance Company
Address
City, 6tate =,3 code

Dear (Contact):

Re:
Case Number: ____________________________
Patient: _________________________________
Date of Injury: ___________________________
Employer: _______________________________
Claim Amount: ___________________________

Our records indicate that payment for the above case number remains unpaid.

Please review the services provided for (patient’s name). Your cooperation in furnishing
us the present status of this claim will be appreciated.

Sincerely,

Your name

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 Solving Problems with Insurance Carriers, Providers and Patients

Managed care plans that utilize the capitation reimbursement system require a
simple accounting sheet. (Remember that capitation plans reimburse physicians
based on the number of patients seen.) Record all patients in one particular plan on
one accounting sheet so you can track how many patients the provider sees. This is
an example of a capitation accounting sheet.

CAPITATION ACCOUNTING SHEET

NAME OF PLAN ________________________

DATE PATIENT NAME CHARGES PAYMENTS

SERVICES/PLAN COPAY/CAPITATION

0205502LB03A-21-13 21-39
Medical Coding and Billing Specialist

 Step 19 Mail-in Quiz 21

 Follow the steps to complete the Quiz.

a. Be sure you’ve mastered the instruction and the Practice Exercises that
this Quiz covers.
b. Mark your answers on your Quiz. Remember to check your answers with the
lesson content.
c. When you’ve finished, transfer your answers to the Scanner Answer Sheet
included. Use only blue or black ink on your Scanner Answer Sheet.
d. Important! Please fill in all information requested on your Scanner Answer
Sheet or when submitting your Quiz online.
e. Submit your answers to the school via mail, fax or, to receive your grade
immediately, submit your answers online at www.uscareerinstitute.edu.

Mail-in Quiz 21
For each item, select the best answer from the choices provided. Each item is worth
5 points.

1. A _____ allows parties to settle disputes without attorneys.

a. small claims court
b. county court
c. default judgment
d. lawsuit

2. When you resubmit an insurance claim, you _____.

a. submit the claim a second time
b. are appealing the insurance reimbursement
c. must contact the insurance commissioner
d. send a narrative explanation as well

3. An example of a delinquent account is _____.

a. Tammy paying with a check that bounces
b. Rhonda making minimum payments
c. Fred submitting his payments late
d. Chris pays her account in full

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 Solving Problems with Insurance Carriers, Providers and Patients

4. Medicare appeals must be filed _____ days from the receipt of the denial.
a. 30
b. 60
c. 90
d. 120

5. You should contact the insurance commissioner _____.

a. any time a claim is denied
b. if you suspect fraudulent claims
c. before resubmitting a claim
d. rather that filing an appeal

6 _____ generates a bill when the insurance company pays its portion of
the claim.
a. Cycle billing
b. The provider
c. Event billing
d. The EOB

7. _____ is a promise to pay later for goods or services immediately received.

a. Credit
b. Debit
c. NSF
d. Charging

8. A tracer _____.
a. allows you to submit medical records to substantiate medical necessity
b. explains procedures listed on the claim
c. enables insurance companies to locate missing claims
d. locates the EOB

9. Negative credit information may be _____.

a. late payments or charges
b. bankruptcies or paying the minimum balance
c. paying the minimum balance or late payments
d. late payments or bankruptcies

0205502LB03A-21-13 21-41
Medical Coding and Billing Specialist

10. Which of the following statements is not true regarding a collection

agency? _____
a. Collection agents collect a commission for every delinquent account
they settle.
b. It specializes in collecting unpaid debts for other businesses.
c. They handle contact, follow-up and financial arrangements for
delinquent accounts.
d. Collection agencies allow business to collect all debt that is owed to them.

11. In which situation should you inquire on the status of a claim? _____
a. A claim is 30 days old and EOB indicates the service was applied
to the deductible.
b. Reimbursement was received for a claim you didn’t file.
c. A claim is 10 days old and no reimbursement has been issued.
d. You should never inquire about the status of a claim.

12. An angry patient receives a bill for services she feels should be covered
by insurance. What should you do? _____
a. Debate with the patient. Ask to see the bill and explain it in order to
prove that you’re correct.
b. Remain calm. Take control of the situation by asking to see the bill.
Answer any questions about the patient’s insurance policy.
c. Remain calm. Take control of the situation by asking to see the
bill. Refer any questions about the patient’s insurance policy to the
insurance representative.
d. Ensure the patient that she is mistaken. Take control of the situation
by asking to see the bill. Answer any questions about the patient’s
insurance policy.

13. When dealing with providers, it’s important to _____.

a. acknowledge your mistakes
b. listen to what he is saying
c. be trustworthy
d. all of the above

14. SECOND BILLING indicates the claim has been _____.

a. resubmitted
b. submitted to the secondary carrier
c. denied by the clearinghouse
d. denied by the primary carrier

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 Solving Problems with Insurance Carriers, Providers and Patients

15. A benefit to clearinghouses includes _____.

a. edited claims and no denials
b. identifying incorrect codes and missing services
c. identifying errors before the claim is sent to the insurance company
d. identifying missing information and ensuring no denials

16. An appeals letter should _____.

a. be filed any time the insurance company denies a claim
b. include why you feel the reimbursement was incorrect
c. be filed with the insurance commissioner
d. include the provider’s fee schedule

17. The _____ should be contacted when an insurance company arbitrarily

denies claims.
a. insurance contact
b. patient
c. provider
d. insurance commissioner

18. When dealing with anxious patients, it’s important to be _____.

a. an adversary
b. right
c. an advocate
d. loud

19. A(n) ____ is a legal document requiring withholding of a percentage of pay.

a. default judgment
b. order of garnishment
c. credit risk
d. judgment

20. To effectively deal with a problem, you must ____.

a. be louder than the provider
b. accept the providers instructions only when you agree with them
c. keep a professional attitude
d. explain to the patient that the provider does not understand the
billing process

0205502LB03A-21-13 21-43
Medical Coding and Billing Specialist

Congratulations!
You have completed Lesson 21.

Drive
Quality n t !
i s h me
mp l
c c o Terrific
A
i n g
rn
Lea
Skillful

Do not wait to receive the results of your Quiz

before you move on.

21-44 0205502LB03A-21-13
 Lesson 22

Introduction to
Coding Terminology:
Medical and Billing
Resources
Word Parts

 Step 1 Learning Objectives for Lesson 22

 When you have completed the instruction in this lesson, you will be trained to do the following:
 Discuss professional organizations pertaining to medical coding and billing,
and explain services they offer.

 Explain credentialing and how it relates to a coding and billing specialist.

 Identify helpful print and Internet publications that relate to the coding and
billing profession.

 Step 2 Lesson Preview

 So far, you’ve studied insurance, medical terminology,
documentation, ethical and legal issues, anatomy and
the basics of medical billing, from completing a claim to
solving problems with insurance, providers and patients!
We’re about to turn our attention to the medical coding
aspect of your new career. Soon you’ll learn how to
determine the correct diagnostic code to apply to
the medical records so you can submit the claim
for reimbursement.

In this lesson, we’re going to step back from the “how-to”

aspect of your training and take a look at your future
career. There are many organizations and resources
available to help you succeed. This lesson is chock full of
information to help you find the guidance you need. We’ll
provide information on the professional organizations
for medical coders and billers. In addition, we’ll discuss
In this lesson, you’ll explore Internet
credentialing and certification options, and peruse
resources and publications that will
resources that can help you stay abreast of changes in the
be helpful in your future career.
healthcare field. In fact, you might be surprised at all the
help that’s out there for you!

0205502LB03A-22-13
Medical Coding and Billing Specialist

 Step 3 Associations for Professional Coders and Billers

 Over the years, several professional organizations have emerged to help healthcare
professionals succeed. These organizations provide educational resources,
community ties, job support and more. The two main associations are the American
Academy of Professional Coders and the American Health Information Management
Association. In the following sections, we’ll take a look at these two associations, as
well as others related to the healthcare profession.

American Academy of Professional Coders (AAPC)

The American Academy of Professional Coders (AAPC) was founded in 1988 as the
American Academy of Procedural Coders. The goal of the original organization was
to provide education, recognition and certification for physician-practice procedural
coders. The AAPC also sought to raise the procedural coding standards.

The AAPC specializes in outpatient coding. Today, the AAPC represents coders who
work for physicians, clinics, hospitals, outpatient facilities, payers and consulting
firms. In all, the AAPC has more than 118,000 members worldwide. Membership is
open to not just coders, but billers and other healthcare information professionals
as well.

The AAPC offers the following coding-related services and programs:

 Coding certification exams and study guides
 Examination review classes
 Coding education
 An annual conference
 Local chapters
 AAPC publications

American Academy of Professional Coders (AAPC)

2480 South 3850 West, Suite B
Salt Lake City, UT 84120
(800) 626-CODE (2633)
www.aapc.com

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 Coding and Billing Resources

American Health Information Management Association (AHIMA)

The American Health Information Management Association (AHIMA) is a membership
organization representing more than 64,000 healthcare professionals. It provides
reliable and valid information for all areas of health management. AHIMA began in
1928 as the Association of Record Librarians of North America (ARLNA). The purpose
of this organization was to “elevate the standards of clinical records in hospitals and
other medical institutions.” This organization has undergone several name changes
over the years. It became AHIMA in 1991. It is recognized as the leading source of
“HIM knowledge,” a respected authority for rigorous professional certification, and one
of the industry’s most active and influential advocates in Congress.1

AHIMA offers a number of services to their members. Among them are:

 Coding certification exams
 Communities of Practice
 Careers Assist: Job Board
 Journal of AHIMA
 Perspectives in HIM

American Health Information Management Association (AHIMA)

233 N. Michigan Avenue, 21st Floor
Chicago, IL 60601-5809
(312) 233-1100 or (800) 335-5535
www.ahima.org

0205502LB03A-22-13 22-3
Medical Coding and Billing Specialist

American Medical Association

Since 1847, the American Medical Association (AMA) has had one mission: to
promote the art and science of medicine and the betterment of public health.2 The
AMA is an important professional organization in the world of health care. The
AMA speaks out on important issues like patient rights and the health of the nation,
and also created and maintains the CPT. The AMA Web site features a variety of
valuable resources. Some of the AMA resources that you might find helpful include:
 CPT code information, including revisions
 CPT licensing
 Annual CPT educational symposium
 CPT Assistant coding journal
 Journal of the American Medical Association (JAMA)
 AMA Code of Medical Ethics

American Medical Association (AMA)

515 N. State Street
Chicago, IL 60654
(800) 621-8335
www.ama-assn.org

American Hospital Association

The American Hospital Association (AHA) serves hospitals, healthcare networks,
patients and communities. The AHA represents the people and organizations in the
development of national healthcare policy.

Some of the AMA resources you might find helpful include:

 Publications covering healthcare legislation
 Research on healthcare services and information management

American Hospital Association (AHA)

155 N. Waker Drive
Chicago, IL 60606
(312) 422-3000 or (800) 424-4301
www.aha.org

Now, let’s look at the credentialing available for medical coding and billing specialists.

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 Coding and Billing Resources

 Step 4 Credentialing
 You’ve probably heard people use the term credentials. Most likely, the word came
up in a conversation about someone’s qualifications for a job. In a market where
there are so many people offering similar services, credentials help people let
customers know they are qualified to do a certain job. There are credentials for
teachers, accountants, attorneys and more! There are also credentials for medical
coding and billing specialists like you.

Credentialing is a growing trend; it validates your skills and knowledge and

sometimes allows for job advancement opportunities. And pay increases! Whether or
not you want to be credentialed is up to you. If you don’t want to do it now, you can
take that leap sometime in the future.

National Healthcareer Association

The National Healthcareer Association (NHA), established in 1989, provides
preparation and certification in various healthcare professions. The Certified Billing
and Coding Specialist (CBCS) exam focuses on converting a medical procedure and
diagnosis into specific codes for submitting a claim for reimbursement. Certification
is not necessary for the medical billing profession; however, according to the NHA,
benefits to obtaining the CBCS “may include more job opportunities, higher wages
and increased job security.”3

For more information about the CBCS exam through the NHA, visit its Web site at
http://www.nhanow.com.

American Academy of Professional Coders

According to the American Academy of Professional Coders, more than 84,000
healthcare professionals around the country hold AAPC certifications. The
AAPC offers certifications in medical coding, auditing, compliance and practice
management. We’ll discuss the requirements of the medical coding certifications.

Certified Professional Coder (CPC)

The Certified Professional Coder (CPC) is the American Academy of Professional
Coder’s main coding certification, with the focus on diagnostic and procedural
codes for outpatient services. In addition to the codes, the CPC’s abilities include
knowledge of coding rules and regulations including compliance and reimbursement.

Full CPC credentialing requires two years of coding experience. However, you can
waive one year of experience with successful completion of this course! You’re almost
halfway there.

0205502LB03A-22-13 22-5
Medical Coding and Billing Specialist

Certified Professional Coder-Hospital (CPC-H)

Another credential offered by the AAPC is the Certified Professional Coder-Hospital
(CPC-H). This credential focuses on outpatient facilities such as ambulatory surgical
centers or hospital outpatient coding and billing departments. In addition to coding
the diagnosis and procedures for outpatient settings, this exam also focuses on
reimbursement procedures, such as fee updates and how to complete the UB-04.

Just like the regular CPC credential, a CPC-H should have at least two years
of coding experience. You can also waive a year of that experience when you
successfully complete your Medical Coding and Billing Specialist course.

Certified Professional Coder-Payer (CPC-P)

The Certified Professional Coder-Payer (CPC-P) demonstrates a coder’s
aptitude, proficiency and knowledge of coding guidelines and reimbursement
methodologies for all types of services from the payer’s perspective, which is the
insurance company. Claims reviewers, utilization management, auditors, benefits
administrators, billing service, provider relations, contracting and customer service
staff can each benefit their practices with the CPC-P credential.

The CPC-P certification exam certifies that the successful candidate has the
knowledge and skills to adjudicate provider claims effectively. The exam tests the
examinee’s basic knowledge of coding-related payer functions with emphasis on how
those functions differ from provider coding. The relationship between coding and
payment functions will be explored in depth.

The CPC-P exam consists of two parts, testing coding accuracy and reimbursement
methodologies. The Medical Coding Concepts section tests the examinee’s
understanding of medical terminology, anatomy and diagnostic and procedural
coding concepts. The Reimbursement Methodologies section covers physician
reimbursement, inpatient payment systems, outpatient payment systems, health
insurance concepts and HIPAA.4

AAPC Apprentice Certifications

Many new coders have the education and basic knowledge to pass the medical coding
certification exams, but not the required amount of experience. This is common with
entry-level coders. To help these people out, the AAPC has an apprentice status.

If you successfully pass the medical coding certification exam but don’t have the
required two years of medical coding experience, you will be awarded the apprentice
status, which is identified by an “A” on the certificate. Like other certifications,
you will have to complete Continuing Education Units (CEUs). When you have
completed the required work experience and submit documentation for that work,
your credentials are upgraded to the full CPC, CPC-H or CPC-P!

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 Coding and Billing Resources

American Health Information Management Association

AHIMA offers three coding certification exams: Certified Coding Associate (CCA), Certified
Coding Specialist (CCS) and Certified Coding Specialist—Physician-based (CCS-P).

Certified Coding Associate (CCA)

The Certified Coding Associate (CCA) is an entry-level coding credential. If you are a
new coder without much experience, you can immediately demonstrate your mastery
of entry-level coding skills by earning the CCA. Earning a CCA also demonstrates a
commitment to coding. It is a good starting point for coding credentials.

To take the CCA certification exam you must have a U.S. high school diploma or
equivalent educational background. It is recommended that you have completed
a formal coding training program, such as the one you’re completing! It is also
recommended, although not required, that you have experience in hospital-inpatient
and ambulatory-care medical coding. AHIMA notes that previous examination
results indicate that persons who have three or more years of coding experience are
more likely to pass the exam.

To download a free, comprehensive Certified Coding Associate Handbook, go to

AHIMA’s Web site. This handbook also explains the CCA exam process in detail.

Certified Coding Specialist (CCS)

Certified Coding Specialists (CCS) are skilled professional coders with solid
experience classifying medical data from patient records, generally from a hospital
setting. A CCS must be an expert in the diagnostic and procedural coding systems.
She must also be fluent in medical terminology, disease processes and pharmacology.

Examples of CCS level work include preparing coded data for Medicare and
Medicaid recipients on the behalf of hospitals and medical providers. This data is
also used by researchers and public health officials to monitor patterns and explore
new interventions.

The CCS certification exam evaluates the individual’s proficiency in coding. On top
of entry-level coding skills, the CCS exam covers some information management
skills. You would consider getting a CCS certification after you have experience
in coding inpatient records. Experience coding the hospital portion of ambulatory
surgery and emergency department care is also helpful. AHIMA recommends at
least three years of experience before taking the CCS exam.

Certified Coding Specialist—Physician-based (CCS-P)

Another type of credentialing offered by AHIMA is the Certified Coding Specialist—
Physician-based (CCS-P). Those with a CCS-P credentialing have expertise in
physician-based settings. This can include doctors’ offices, group practices, specialty
centers and multi-specialty clinics. CCS-P coders have in-depth experience with diagnostic
and procedural codes. They also are experts in health information documentation.

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Medical Coding and Billing Specialist

With the growth of managed care, the future looks good for this specialty. So if you
develop solid experience and proficiency coding in a doctor’s office, clinic or similar
setting, you might want to consider obtaining the CCS-P certification to attest to
your ability.

Here is a final note regarding the AHIMA certifications. According to AHIMA, “the
CCA exhibits coding competency in any setting, including both hospitals and physician
practices. The CCS and CCS-P exams demonstrate mastery level skills in an area of
specialty: hospital-based for CCSs and physician practice-based for CCS-Ps.”5

You can contact the NHA, AAPC or AHIMA for more information on all of these
certifications. Before moving on to coding and billing resources, let’s review what
you’ve learned.

 Step 5 Practice Exercise 22-1

 Determine the term(s) to complete each sentence.

1. ________________ are skilled professional coders with solid experience

classifying medical data from patient records.

2. ____________________ is recognized as one of the industry’s most active

and influential advocates in Congress.

3. The _____________ exam focuses on converting a medical procedure and

diagnosis into specific codes for submitting a claim for reimbursement.

4. The AMA speaks out on important issues like ____________________

_______________________ and the health of the nation.

5. The ____________ exam tests the student on diagnostic and procedural

codes, compliance and reimbursement policies.

6. In addition to coding the diagnosis and procedures for outpatient

settings, the ____________________ exam also focuses on reimbursement
procedures, such as fee updates and how to complete the UB-04.

7. The goal of the ______________ is to provide education, recognition and

certification for physician-practice procedural coders.

8. _____________________ coders have in-depth experience with diagnostic

and procedural codes. They also are experts in health information
documentation.

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 Coding and Billing Resources

 Step 6 Review Practice Exercise 22-1

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 7 Coding and Billing Resources

 Whether you’re just embarking on your coding and billing career or are an
experienced coder and biller, you will need to be up-to-date on coding developments.
You will always rely on resources to help you find codes and information on
healthcare issues. Why are resources so important to coders? It is not humanly
possible to remember every diagnostic or procedural code. Also, new and revised
codes are published annually. Resources serve a number of functions:
 Reference books allow you to store the information you don’t use
every day.
 Resources can provide you with the information right now, when
you need it.
 Resources serve as a valuable support system if you are working
independently or don’t otherwise have much contact with other
people where you work.

The professional organizations you just learned about will be very helpful to you
in your new career. Now, we’ll provide some resources from these professional
organizations and others! Consider them as a starting point from which to develop
your own pool of coding resources. They will give you a good idea of what’s available.

AAPC Publications
Member of the AAPC, receive various publications to keep up-to-date on coding
trends. These publications include Coding Edge, EdgeBlast and BillingInsider.
 Coding Edge is a monthly print publication that is written by and for
members of the AAPC. Articles include issues facing the coding industry
and updates on emerging trends and concerns. Members of the AAPC can
subscribe to the coding news magazine.
 EdgeBlast is a newsletter distributed by e-mail twice a month to AAPC
members. It includes summaries and links to important articles.
 BillingInsider is an e-newsletter available to members and nonmembers.
Topics relate to the billing side of the medical practice.

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Medical Coding and Billing Specialist

AHIMA Publications
AHIMA provides both online and in print publications relating to the healthcare
field. These publications include the Journal of AHIMA and Perspectives in HIM. In
addition, members have access to an online tool for healthcare professionals.

AHIMA’s Communities of Practice (CoP) is an online tool that AHIMA members

use to network, share, problem-solve and stay informed of the latest trends in
HIM-related topics. This growing professional network provides answers, support
and career advice using the latest technology.6

The Journal of AHIMA is a monthly journal that includes both coding-specific and
general health information management related articles. It also includes tips for
on-the-job solutions and practical guidance on regulations, policies and procedures.
This journal is available to nonmembers by subscription.

Perspectives in Health Information Management is a scholarly, peer-reviewed

research journal that aims to advance health information management practice
and encourage interdisciplinary collaboration between healthcare professionals
and others in disciplines supporting the advancement of the management of health
information.7 It’s an online journal that is free to members and nonmembers.

AHIMA e-Newsletters
AHIMA e-newsletters are primarily for members of AHIMA. You can find a complete
listing of the e-newsletters on the AHIMA Web site.
 Academic Advisor is a quarterly e-newsletter for HIM educators.
 CodeWrite is a monthly e-newsletter containing coding, reimbursement
and compliance information.
 Members receive AHIMA Advantage electronically six times each year.
This publication includes healthcare and AHIMA news. In addition,
members receive AHIMA Advantage E-Alerts weekly, which deliver
news summaries on industry, AHIMA and government news related to
healthcare. Members can view the most recent issue on the CoP.

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 Coding and Billing Resources

American Medical Association

The AMA produces the CPT Assistant, the Journal of the American Medical Association
and a slew of coding reference material, including express reference cards, specialty
coding references and electronic data files of technical coding manuals.

The CPT Assistant is a monthly newsletter only available to AMA members. It provides
detailed articles, commentaries and updates to keep your claims system running.

The Journal of the American Medical Association (JAMA) has been published
continuously since 1883. It is an international peer-reviewed general medical journal
published 48 times per year.8 Its objective includes publishing original, important,
valid, peer-reviewed articles on a diverse range of medical topics.

American Hospital Association

The Coding Clinic is quarterly publication that provides official coding guidelines
and advice. A subscription allows you to access past issues for updates about
coding-specific conditions or procedures.

OptumInsight
OptumInsight, previously Ingenix, publishes many of the coding manuals. In addition,
OptumInsight offers a comprehensive mix of coding, billing, reimbursement and
compliance products in a wide array of formats and services. These include Web-based
tools, books, desktop software and print and electronic updates.

Among the many publications that might be of particular interest to you as a medical
coding and billing specialist are:
 Coder’s Dictionary. This dictionary is written by coders for coders. It includes
definitions for medical nomenclature, eponyms, new technology and acronyms.
 DRG Expert. The nation’s DRG information experts bring you this annual
book organized by Major Diagnostic Category (MDC) for accurate assignment
of DRGs and maintenance of the highest level of data quality. This book is for
those who need to either accurately assign DRGs or verify DRG information.
 Uniform Billing Expert. This reference tool assists in managing the constant
changes to Medicare billing and reimbursement. It provides information
about UB-04 billing rules and requirements.
 Outpatient Billing Expert. This reference applies to hospital outpatient
departments and free-standing ambulatory surgical centers. It provides
guidance to improve reimbursement and reduce denied claims.
 Coder’s Desk Reference for Diagnoses. This reference allows you to better
understand the clinical meanings behind codes. It provides coding tips
and includes coding scenarios to demonstrate the application of the codes.
 Coder’s Desk Reference for Procedures. This manual helps you identify the
differences between CPT codes that seem very similar.

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Medical Coding and Billing Specialist

You can access an online catalog of Optum/Ingenix products and services at

www.optumcoding.com. You can also call 1-800-464-3649, option 1, to request a
print catalog.

OptumInsight
2525 Lake Park Blvd.
Salt Lake City, UT 84120
(801) 464-3649
www.optumcoding.com

Just Coding
The Just Coding Web site provides answers to coding questions, access to coding
articles and discussion groups, a free e-newsletter, job opportunities and a number of
links to other helpful Web sites. Among the useful tools and links are the following:
 Continuing Education credits via articles, quizzes or Webcasts.
 Coding and reimbursement updates.
 Boot Camps, conferences and Webcasts.
 Coding guidance, practice questions and expert analysis.
 CPC practice exam and Job Board.

JustCoding.com
75 Sylvan Street
Suite A-101
Danvers, MA 01923
(800) 650 6787
www.justcoding.com

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 Coding and Billing Resources

National Institute of Health

The National Institute of Health is the steward of medical and behavioral research
for the United States. NIH funds scientific studies at universities and research
institutions across the country. NIH is made up of 27 Institutes and Centers, each
with a specific research agenda, often focusing on particular diseases or body systems.

If you visit the NIH Web site search for “medical coding,” you will find a wide range
of resources. There are publications, reports and research documents available—
all related to coding. In the field of medical coding, the impact of ongoing medical
research is great. The coding manuals are constantly being updated and revised to
reflect new information that becomes available in medicine. The NIH is one of the
primary resources for the details of such research.

National Institute of Health (NIH)

9000 Rockville Pike
Bethesda, MD 20892
(301) 496-4000
www.nih.gov

Other Coding and Billing Resources

A number of other companies and organizations provide a variety of coding- and
billing-related resources. Here are a few that you might want to check out as you
develop your network of resources.

For The Record

For The Record is published biweekly and provides reliable information on a range of
health information issues. The subscription is free to members of the AACP and some
members of AHIMA. The magazine is available in print, digital or both. For more
information, visit the Web site at www.fortherecordmag.com or call (800) 278-4400.

Advance for Health Information Professionals

Advance for Health Information Professionals offers a free e-newsletter that provides an
editorial advisory board, hands-on help and CCS prep information. You’ll also receive
notices on free Advance Job Fairs and job postings. The Web site for this publication is
http://health-information.advanceweb.com. To subscribe by phone, call (800) 355-1088.

MedicalCoding.net
MedicalCoding.net was founded in 2001. It is a subsidiary of Provistas, Inc.
MedicalCoding.net presents a variety of medical coding, billing and compliance books,
eBooks, data files, claims forms and software to complement Provistas’ educational
and consulting programs. Provistas is focused on providing Medicare compliance
solutions to hospital and physician-practice clients. You can also subscribe to e-mail
news at the Web site www.medical-coding.net or call (888) 288-2043.

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The Coding Institute

The Coding Institute is a national newsletter publishing company. This group offers
a wide range of medical specialty newsletters, coding bulletins, audio conferences,
video coding series, CDs, print transcripts and online discussion groups. Contact The
Coding Institute for information about free, sample newsletters at (800) 508-2582 or
www.codinginstitute.com.

RAmEX Ars Medica, Inc.

RAmEX Ars Medica, Inc. distributes medical multimedia materials for professionals,
including billing and coding specialists. Resources include medical CD-ROMs,
medical videos, medical books, medical journals, medical slides, medical audio tapes
and other medical software covering a broad range of medical fields and topics. You
can find out more about RAmEX Ars Medica products by visiting the Web site at
www.ramex.com or calling (800) 633-9281.

Online Medical Dictionaries

If you have Internet access, perhaps you’ve discovered the handiness of online
dictionaries. Many of them are even free! In particular, the medical dictionaries listed
below can be an excellent source of information and support. Some of these Web sites
include a variety of medical information and resources in addition to the dictionary.
Take a few minutes to visit each Web site and bookmark them for future reference.
 www.online-medical-dictionary.org
 www.medical-dictionary.com
 www.medic8.com/MedicalDictionary.htm
 www.medterms.com
 www.medicinenet.com
 www.sciencekomm.at/advice/dict.html

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 Coding and Billing Resources

 Step 8 Practice Exercise 22-2

 Identify the coding resource with the company or organization where you can find it.

1. __________ BillingInsider

2. __________ CPT Assistant

3. __________ Coding Clinic

4. _________________________________ Coder’s Desk Reference for Diagnoses

5. __________ Communities of Practice

6. _________________________________ Coder’s Desk Reference for Procedures

7. __________ Coding Edge

 Step 9 Review Practice Exercise 22-2

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 10 Lesson Summary

 You’ve probably heard the expression “the more you know, the more you’ll grow.”
When it comes to medical coding and billing, that saying is exactly right. In this
profession, you must keep up-to-date with coding regulations, medical advances
and professional trends. The resources in this lesson are your Yellow Pages, grape
vine and encyclopedia—all rolled into one. Whether you’re searching for information
on the latest coding changes or claims updates, these resources are a great place
to start. As you explore these resources and network with other coding and billing
specialists, you’ll no doubt find other sources of information that you like.

Don’t feel overwhelmed. There’s more information in these resources than anyone
could read through. What’s important is that you know where to begin your search if
you have any questions. You’ve learned a lot so far, so keep up the good work!

One final note: Web site addresses and phone numbers change frequently. The
addresses and numbers listed in this lesson were current at the time of printing,
but they may change in the future. You may want to keep a list of your favorite
resources, and update the contact information regularly.

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Medical Coding and Billing Specialist

 Step 11 Mail-in Quiz 22

 Follow the steps to complete the Quiz.

a. Be sure you’ve mastered the instruction and the Practice Exercises that
this Quiz covers.
b. Mark your answers on your Quiz. Remember to check your answers with the
lesson content.
c. When you’ve finished, transfer your answers to the Scanner Answer Sheet
included. Use only blue or black ink on your Scanner Answer Sheet.
d. Important! Please fill in all information requested on your Scanner Answer
Sheet or when submitting your Quiz online.
e. Submit your answers to the school via mail, fax or, to receive your grade
immediately, submit your answers online at www.uscareerinstitute.edu.

Mail-in Quiz 22
Select the best answer from the choices provided. Each item is worth 5 points.

1. Two main associations for coders are _____.

a. AHIMA and AHA
b. AMA and AHA
c. AAPC and AHIMA
d. AHA and AAPC

2. AHIMA’s Communities of Practice is a(n) _____.

a. networking tool to meet other coders and find information
b. online store to purchase coding manuals
c. collection of practice exams for the CCS exam
d. group of healthcare providers who advise AHIMA members

3. The AAPC offers _____ to keep coders up-to-date on emerging trends.

a. Prospectives in HIM
b. Coding Edge
c. CPT licensing
d. CPT Assistant

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 Coding and Billing Resources

4. Credentials can help you _____.

a. validate your skills and knowledge
b. get promoted
c. get raises
d. all of the above

5. Entry-level coders can earn a(n) _____.

a. CCA
b. CPC-H
c. AMA
d. CCS

6. CCSs must be _____.

a. entry-level coders
b. experienced in medical billing
c. able to demonstrate entry-level coding skills
d. experts in the diagnostic coding system

7. Which certification focuses on submitting claims for reimbursement? ____

a. CCA
b. CBCS
c. CPC
d. AMA

8. Which organization has the mission of promoting the art and science of
medicine? _____
a. AAPC
b. AMA
c. AHA
d. AHIMA

9. Which of the following is not a reason for using coding resources? _____
a. Reference books allow you to store the information you don’t
use every day.
b. Resources can provide you with the information right now,
when you need it.
c. Resources answer coding questions that come up, so you don’t
have to know the steps for diagnostic and procedural coding.
d. Resources serve as a valuable support system if you are
working independently.

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Medical Coding and Billing Specialist

10. _____ is a monthly e-newsletter containing coding, reimbursement and

compliance information.
a. EdgeBlast
b. CodeWrite
c. Journal of AHIMA
d. Academic Advisor

11. To find out about current medical research being conducted by the
government, you could go to _____.
a. www.ramex.com
b. www.medterms.com
c. www.medical-coding.net
d. www.nih.gov

12. _____ is a national company that publishes medical newsletters.

a. Provistas
b. The Coding Institute
c. RAmEx Ars Medica, Inc.
d. Coding Edge

13. The following are all _____: www.medterms.com, www.medicinenet.com

and www.sciencekomm.at/advice/dict.html.
a. discussion boards
b. online publications
c. search engines
d. print publications

14. If you passed the CPC exam but do not have two years of coding
experience, _____.
a. you will not receive the CPC credential
b. you will not receive full CPC credentialing
c. you will receive the apprentice status
d. both b and c

15. The certification from the payer’s prospective is the _____.

a. CPC
b. CCS
c. CPC-P
d. CCS-P

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 Coding and Billing Resources

16. A new coder without much experience can take the exam for the _____.
a. CCA
b. CCS
c. CPC
d. CPC-H

17. _____ is a quarterly e-newsletter for HIM educators.

a. Coding Edge
b. Academic Advisor
c. Communities of Practice
d. JAMA

18. _____ is a reference tool that provides information about UB-04 billing
rules and requirements.
a. Outpatient Billing Expert
b. Uniform Billing Expert
c. DRG Expert
d. BillingInsider

19. The _____ assists coders with the clinical meanings behind diagnostic codes.
a. Coder’s Dictionary
b. Coders Edge
c. Coder’s Desk Reference for Procedures
d. Coder’s Desk Reference for Diagnoses

20. _____ is an e-newsletter related to the billing side of medical practice.

a. Outpatient Billing Expert
b. Uniform Billing Expert
c. DRG Expert
d. BillingInsider

Endnotes
1
AHIMA Facts. American Health Information Management Association. Web. 28 June 2012.
2
About the American Medical Association (AMA). American Medical Association. Web. 28 June 2012.
3
Billing and Coding Specialist Certification (CBCS). National Healthcareer Association. Web. 28 June 2012.
4
Certified Professional Coder-Payer (CPC-P®). AAPC. Web. 28 June 2012.
5
Certified Coding Associate (CCA). American Health Information Management Association. Web. 28 June 2012.
6
Getting Started in AHIMA’s Communities of Practice (CoP). American Health Information Management
Association. Web. 28 June 2012.
7
About the Journal. American Health Information Management Association. Web. 28 June 2012.
8
About JAMA. American Medical Association. Web. 28 June 2012.

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Medical Coding and Billing Specialist

Congratulations!
You have completed Lesson 22.

Drive Terrific

Quality !
n t
i s h me
mp l
c c o
A
Learn
ing
Skillful

Do not wait to receive the results of your Quiz

before you move on.

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 Lesson 23

Introduction to
ICD-9-CM
Medical Coding
Terminology:
Introduction
Word Parts

 Step 1 Learning Objectives for Lesson 23

 When you have completed the instruction in this lesson, you will be trained to do the following:
 Describe the history and development of the diagnostic coding system.
 Explain the role of medical coding and its uses.
 Compare and contrast the ICD-9-CM and ICD-10-CM coding systems.
 Explain how Volumes 1 and 2 of the ICD-9-CM are organized.
 Explain basic coding guidelines.
 Distinguish among the ICD-9-CM conventions.
 Describe ICD-9-CM terminology.
 Locate the appendices in the ICD-9-CM.
 Identify the steps to diagnostic coding.

 Step 2 Lesson Preview

 Are you wondering when you’ll get to code? Well,
here we go! This lesson will introduce you to
diagnostic coding.

Whenever a patient sees a doctor for a

health-related problem, the patient is asking for
a diagnosis. We’ve talked quite a bit about
diagnoses in previous lessons, and you already
know a bit about diagnosis codes. You also know
that when a doctor makes a diagnosis, it is you, the
medical coding and billing specialist, who codes it.
Whenever a patient sees a doctor for
a health-related problem, the patient
is asking for a diagnosis.

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Medical Coding and Billing Specialist

The diagnosis codes that you assign are then used to determine the medical necessity.
This helps the payer, such as the insurance companies, to determine reimbursement for
the physician’s services.

If you haven’t borrowed or purchased the current ICD-9-CM manual, now is the
time! You’ll begin using it in this lesson as we discuss the manual’s two volumes and
the various aspects of each.

This lesson also will give you information on the appendices, chapters and sections of
each volume of the ICD-9-CM. Perhaps one of the most important aspects of this lesson
is that you will learn about the various ICD-9-CM conventions. These conventions
are the accepted ways of doing things when it comes to medical coding. When you
understand these conventions and how they are used, you will have no problem
accurately assigning diagnostic codes in your work.

 Step 3 History of the International Classification

of Diseases
 We spoke briefly of the International Classification of Diseases in a previous lesson.
The history of the ICD dates back to the 1600s in England! The system came to the
United States in the mid-1700s. This classification of diseases originally was used to
track mortality statistics to determine how many people died of different diseases.

In the seventeenth century, the statistical study of

diseases began with the work of John Graunt on the
London Bills of Mortality. The Bills was initially a list
of only the number of burials. Graunt added to the Bills,
to include the cause of deaths. He tabulated and studied
the data from the annual bills from 1629 through 1660
and published Natural and Political Observations Made
upon the Bills of Mortality in 1662. This publication is
considered one of the forerunners of today’s international
mortality classifications.

In 1837, the General Register Office of England and

Wales found its first medical statistician, William Farr.
Farr labored to secure an improved classification, as
well as international uniformity. In 1853, the first
International Statistical Congress (ISC) asked Farr
to prepare an internationally applicable, uniform
classification of causes of death.1 Although this The ICD originally was used to
classification was never universally accepted, the general track mortality statistics.
arrangement survived as the basis of the International
List of Causes of Death.

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 ICD-9-CM Coding Introduction

The International Statistical Institute created a committee, chaired by Dr. Jacques

Bertillon, to prepare a classification of causes of death. The report was presented in
1893, and the Bertillon Classification of Causes of Death, as it was first called, received
general approval. Several countries adopted it at that point. Jesus E. Monjaras first
used the classification in the Americas for the statistics of San Luis de Potosi, Mexico.2

In 1900, the first international conference for the revision of the Bertillon or
International List of Causes of Death convened. Representatives from 26 countries
attended and adopted the first of the ICDs or International Classification of
Diseases. It was determined that the classifications should be revised every 10
years; therefore, the succeeding conferences were held in 1909, 1920, 1929 and
1938, and a new version of the ICD was adopted at each.3

The WHO
The World Health Organization (WHO) is the directing and coordinating
authority for health within the United Nations system. It is responsible for
providing leadership on global health matters, shaping the health research
agenda, setting norms and standards, articulating evidence-based policy options,
providing technical support to countries and monitoring and assessing health
trends.4 In 1946, the United Nations gave the responsibility of the ICD to the
WHO, which issued the sixth and subsequent revisions in 1948, 1958 and 1967.

The ICD is the international standard diagnostic classification. It classifies diseases

and other health problems recorded on many types of health and vital records,
including death certificates and health records.5

ICD-9-CM
The World Health Organization published the 9th Revision,
International Classification of Diseases (ICD-9) in 1977.
In 1979, the United States adopted the International
Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM) based on the ICD-9. The Clinical Modification
expanded the number of diagnosis codes and developed a
procedural coding system.

The ICD-9-CM consists of:

 Tabular List
 Alphabetical Index
 Procedure Alphabetic Index and Tabular List

The Clinical Modification expanded

the number of diagnosis codes and
developed a procedural coding system.

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Medical Coding and Billing Specialist

Reminder!
Do you have access to a diagnostic coding manual yet? You’ll need it to
complete the remaining instruction packs.

You can either borrow one from your local library, if your library has a current
version, or purchase your own manual at a special student rate. Look for the
coupon in your instructional materials, or call Student Services at 800-347-7899
for more information.

 Step 4 Why Code?

 Through the years, the number of people who go to the doctor has increased. This
increase has occurred for several reasons:
 People live longer and require more health care.
 Technological advances offer more options for better health care.
 People have better access to health care than ever before.

Your role as the medical coding and billing specialist is to translate the physician’s
written diagnoses for all of these patients into numeric (number codes) and
alphanumeric (combined letter and number) codes, and then submit claims for
reimbursement. The physician’s office uses this coded information for a number
of purposes. A primary use of medical codes is to communicate to the insured the
reason for a patient’s medical visit. Thus, the diagnosis code communicates to the
insurance payer the reason the physician provided medical services for the patient.

Another use for medical coding is as a statistics-gathering tool for

research, grants and financial analysis. Hospitals use coding to
index hospital records according to diseases and operations.
By indexing—or organizing—records this way, they
consistently can store and retrieve data. Coding is
useful for reporting medical diagnostic trends to
agencies that track this information. For instance,
the American Cancer Society can access accurate
cancer statistics thanks to coding.

As you can see, the coding system is a common

language that the medical community uses as a
standard communications device. Using this coding
system correctly is important. You know by now that
Medical coding can be used as a if a code is used that does not match the services
statistics-gathering tool for research, performed, the claim will be rejected. In addition, for
grants and financial analysis. government claims, such as to Medicaid or Medicare,
the correct code is required by law.

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 ICD-9-CM Coding Introduction

Originally, medical coding was used to allow access to medical records for easy
retrieval of information for medical research, education and administration. Today,
coding is used to:
 Facilitate payment of medical services.
 Study patients’ use of healthcare facilities.
 Study the cost of health care.
 Research the quality of health care.
 Determine healthcare trends.
 Plan for future healthcare needs.

 Step 5 ICD-10
 After 30 years, the ICD-9 needs to be replaced. The terminology and classification
of some conditions are outdated and/or obsolete. These outdated codes produce
inaccurate and limited data. And, the limits of the categories result in an increasing
lack of specificity. Finally, the ICD-9-CM hinders comparisons with international
data. It’s clear that the ICD must be flexible enough to adjust for emerging diagnoses
and procedures and exact enough to identify precise diagnoses and procedures.

In 1989, the WHO prepared the International Statistical Classification of Diseases

and Related Health Problems, 10th Revision (ICD-10), which was released in
1994. The United Kingdom adopted it in 1995, followed by the Nordic countries of
Denmark, Finland, Iceland, Norway and Sweden from 1994 through 1997. Each
year, another country adopted the ICD-10: France (1997), Australia (1998), Belgium
(1999), Germany (2000) and Canada (2001). On January 15, 2009, the Department
of Health and Human Services (HHS) released the final rule for the implementation
of the International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM) and the International Classification of Diseases, 10th Revision,
Procedural Classification System (ICD-10-PCS). The final rule established the
upcoming ICD-10 (both CM and PCS) transition.

To read about the ICD-10 Final Rule, visit:

http:edocket.access.gpo.gov/2009/pdf/E9-743.pdf

On April 17, 2012, the HHS released a notice to postpone the date of compliance to
October 1, 2014.

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Impact for Coders

How does this affect you? Is it a waste of time to learn coding from the ICD-9-CM?
Absolutely not! Per U.S. government mandate, the ICD-9-CM will be used by all
medical service providers up until midnight on September 30, 2014. The ICD-10-CM
will be implemented on October 1, 2014. To make sure you have the information
about the current industry standard, we will focus on discussing the ICD-9-CM in
your course for the immediate future. Once you are familiar with the coding process
with the ICD-9-CM, it’ll be a smooth transition to the ICD-10-CM. You can get
reference material in the format of an ICD-10-CM supplement available for purchase
online through our bookstore. This supplement is optional and is not a required part
of your course.

 Step 6 ICD-9-CM vs. ICD-10-CM

 Let’s briefly review the two different code sets and compare them.

ICD-9-CM ICD-10-CM
Codes are 3 to 5 characters in length Codes are 3 to 7 characters in length
Approximately 15,000 codes Approximately 68,000 codes
First digit may be alpha (E or V) or numeric; Digit 1 is alpha; digits 2 through 7 are
digits 2 to 5 are numeric alpha or numeric
Limited space for new codes Flexible for adding new codes
Lacks details Very specific
Lacks laterality, which means left, right, Has laterality (For example, the ICD-10-CM
or both sides is not defined (For example, identifies which arm, such as right, left or
with the ICD-9-CM, you might know that a both, the patient broke.)
patient’s arm is broken, but you don’t know
if it was the right or left or even both arms.)
Difficult to analyze data due to Specificity improves coding accuracy and
non-specific codes depth of data for analysis
Codes are non-specific and do not Detail improves the accuracy of data
adequately define diagnoses needed for used in medical research
medical research
Does not support the ability to share data Supports interoperability and the
because it is not used in other countries exchange of healthcare data among
other countries and the United States

Now that you understand the need for the ICD-9-CM update, let’s pause for a
quick review.

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 Step 7 Practice Exercise 23-1

 Choose the best answer from the choices provided.

1. The ICD originally was used to track _____.

a. new diseases
b. mortality statistics
c. clinical diagnoses
d. population statistics

2. The Bertillon Classification of Causes of Death was first used in the

Americas in which country? _____
a. United States
b. Canada
c. Mexico
d. England

3. In 1946, the United Nations gave the responsibility for the ICD to the ____.
a. World Health Organization
b. General Register Office of England and Wales
c. International Statistical Institute
d. International Statistical Congress

4. The United States adopted the International Classification of

Diseases, 9th Revision, Clinical Modification (ICD-9-CM), is based
on the ICD-9, in _____.
a. 1946
b. 1977
c. 1967
d. 1979

5. The ICD-9-CM consists of a(n) _____.

a. tabular list
b. alphabetical index and procedural index
c. procedure index and tabular list
d. tabular list, alphabetical index and procedure alphabetic index and
tabular list

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Determine the correct answer to complete each sentence.

6. A primary use of medical codes is to ________________________________ to

the insured the reason for a patient’s medical visit.

7. Medical coding is a ____________________________________________________

for research, grants and financial analysis.

8. The ICD-9-CM outdated codes produce ________________________________

___________________________________________________.

 Step 8 Review Practice Exercise 23-1

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 9 Organization of Volume 2, Alphabetic Index

to Diseases ICD-9-CM
 Before you really can begin coding, you need to understand the
format and organization of the ICD-9-CM manual, Volumes
1 and 2. The manual itself is available from a number of
different sources and publishers. Each publication presents the
information in the ICD-9-CM manual in a slightly different
format. For our purposes, all references to the ICD-9-CM
manual, general arrangement and specific examples used
are based on Optum, Inc.’s 2013 Professional ICD-9-CM for
Physicians, Volumes 1 & 2 ©.

You may see an ICD-9-CM manual that contains three

volumes, but, in this course, we will use only Volumes 1
and 2. You will not use Volume 3 because it is used by
hospitals for coding of inpatient procedures. Inpatients are
those people admitted to a hospital or clinic who require at
least a 24-hour stay for treatment. Outpatients receive You need to understand the
treatment but do not necessarily need to stay for a 24-hour format and organization of
period at a medical facility. the ICD-9-CM manual.

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When you begin your search for diagnostic codes in the ICD-9-CM, you first look in
the Alphabetic Index to Diseases, or Volume 2 of the ICD-9-CM. It is located first in
the manual but is called Volume 2. Confusing, isn’t it? The ICD-9-CM originally was
organized with Volume 1 before Volume 2, but medical coders found they always
started their search in Volume 2 to locate codes. So, Volume 2 is presented first to
make the manual user friendly.

Volume 2 is divided into three sections. Each section lists topics with a title and
a description of the information that will be covered. The following are the names
of these three sections and a brief description of each section’s contents:
 Section 1—Index to Diseases—An alphabetical list of diseases with the
corresponding diagnostic codes.

 Section 2—Table of Drugs and Chemicals—An alphabetical table listing

substances to identify poisoning and external causes of adverse effects of
drugs and other chemical substances.

 Section 3—Index to External Causes—An alphabetical list of external

causes of injury and poisoning.

Think of this lesson as your guide to understanding the ICD-9-CM. Right now, take
time to locate these sections in Volume 2 of your ICD-9-CM coding manual. As you
become familiar with your manual, coding will get easier and become more fun!

Main Terms
The first important skill to develop in medical coding is the ability to identify main
terms for the diagnosis in a medical statement. A medical statement is information
a doctor documents in a patient’s medical record, such as, “The patient is diagnosed
with arm pain.” You assign codes for the patient’s chief complaint or symptoms when
there is no other definitive diagnosis or cause listed for the condition. When you
code a record that contains two or more equal diagnoses, the principal or primary
diagnosis is the one for which the main treatment was given.

Main terms appear in boldface type in Volume 2 of the ICD-9-CM and are flush with
the left margin of each column for easy reference. Main terms represent items such
as the following:
Diseases – for example: influenza, bronchitis

Conditions – for example: fatigue, fracture, injury, complication

Nouns – for example: disease, disturbance, syndrome

Adjectives – for example: double, large, kink

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Anatomical sites, which are locations on the body, are not used for main terms.
For example, you will find bronchial asthma under the disease term asthma, not
under the anatomical term bronchial. When you look up the term asthma in the
Alphabetic Index of Diseases—or Volume 2—the first entry you’ll find for the main
term is as follows:
nonessential modifiers

Asthma, asthmatic (bronchial) (catarrh) (spasmodic) 493.9

main terms diagnosis code

The terms you see in parentheses after the word asthmatic are called nonessential
modifiers. We will discuss nonessential modifiers later when we talk about the
punctuation used in the ICD-9-CM.

Let’s practice identifying main terms. Try coding the statement, “The patient is
diagnosed with abdominal pain.” Begin by asking yourself, “What did the doctor
document as being wrong with the patient?” Well, you know that the patient has
abdominal pain. Now, where do you begin your search—abdominal or pain? You
know that main terms in the ICD-9-CM are not listed under anatomical sites,
so you can rule out looking under the term abdomen. Pain is a condition, so you
would look there first. Following is an example of an entry from the Alphabetical
Index to Diseases in the ICD-9-CM. You can see how the main term pain is listed.
main term Pain(s) (see also Painful) 780.96
abdominal 789.0 
acute 338.19
due to trauma 338.11
subterms postoperative 338.18
post-thoracotomy 338.12
adnexa (uteri) 625.9
alimentary, due to vascular insufficiency 557.9

Subterms
In the example, the term abdominal describes where the pain is located in
the body. Locating abdominal is the second step in determining what code
to use. The first step was to identify pain as the main term. In this example,
abdominal is a subterm. All terms listed below the main terms are called
subterms. Subterms are modifiers of main terms and always are indented two
spaces to the right below main terms. Each subterm has its own line, and all
subterms are arranged in alphabetical order. Subterms describe the following
three categories:
 Site—location on the body
 Cause—reason
 Clinical type—form

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Look at the following examples:

The diagnosis is: viral infection
The main term is: infection
The subterm is: viral

The main term, infection, is a condition. The subterm, viral,

is the clinical type or form of infection. Let’s try one more:
The diagnosis is: Addison’s Disease
The main term is: Disease
The subterm is: Addison’s

The main term, disease, is a noun—a person, place or

thing. The subterm, Addison’s, tells you the type of disease.
The main term, disease, is a
Other Important Terms noun—a person, place or thing.
Carryover lines appear in the manual because there is a limit to the number of
words that can fit on a single line of print in the Index. In entries that don’t fit on
a single line, the extra words carry over to the next line and usually are indented
an additional four spaces. The following demonstrates a carryover line:
Rubella (German measles) 056.9 [main term]
complicating pregnancy, childbirth
or puerperium 647.5  [carryover line]
Let’s take a moment to talk about nonessential modifiers. Nonessential modifiers follow a
main term or subterm in parentheses. However, when you are dealing with nonessential
modifiers, the presence or absence of the information in parentheses has no bearing on
your selecting the correct code. In other words, the information does not necessarily need
to be documented in order for you to determine which code is correct for the diagnosis. An
example of a main term with nonessential modifiers follows:

Pneumonia (acute) (Alpenstich) (benign) (bilateral) (brain) (cerebral)

Do you remember talking about eponyms in the medical terminology lessons?

Eponyms are diseases or operations named for persons. The main terms for
eponyms are found in the Index to Diseases under the eponym itself or under the
main term, such as Disease, Syndrome and Disorder. For example, if you look
in the index under the eponym Alzheimer’s disease, you find the following:
Alzheimer’s
disease or sclerosis 331.0

If you look under the main term Disease, you’ll find:

Disease, diseased
Alzheimer’s—see Alzheimer’s

In this case, you would go back to Alzheimer’s in the Index to Diseases to locate
code 331.0. We will talk about see and see also later in this lesson.

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Terms not listed in the Tabular List, or Volume 1 of the ICD-9-CM, occasionally are
provided only in Volume 2, the Alphabetic Index to Diseases. In these cases, only similar
terms are included in the Tabular List, and you should follow the Alphabetic Index to
Diseases for the correct code. An example of a term listed in Volume 1, the Tabular List
but listed differently in Volume 2, Section 1, Index to Diseases, follows:
780.79 Other malaise and fatigue
Asthenia NOS
Lethargy
Postviral (asthenic) syndrome
Tiredness
However, in Volume 2, Index to Diseases, you find this term:
Listlessness 780.79
Although listlessness is assigned a code, 780.79, in Volume 2, Section 1, the Index to
Diseases, that term is not listed in Volume 1, the Tabular List description under
the same code. In this case, you should note that similar terms were shown in the
Tabular List; however, trust the guidance of the Index to Diseases and use the
code indicated there. You will find that the Tabular List may not have the exact
description as the medical record. It is up to you, the medical coding and billing
specialist, to decide which code is most specific for a diagnosis. Don’t worry, your
upcoming lessons will prepare you to do that, but remember to trust the guidance
that the Index to Diseases provides.

 Step 10 Organization of Volume 1, Tabular List

 Volume 1 of the ICD-9-CM is referred to as the Tabular List and is presented
second in the manual. The Tabular List is a numerical index of specific diagnosis
codes. This list is cross-referenced with diseases and injuries according to the
anatomical system affected and/or the etiology, which is the cause of the disorder.
Volume 1 is divided into seven parts: three sections and four appendices. The
three sections consist of codes 001-999.9, the V codes and the E codes. Following
those are the four appendices which we will discuss later in this lesson. Always
be familiar with the organization of the coding manual you are using because the
format will vary according to publishers.

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 ICD-9-CM Coding Introduction

The first section of Volume 1 contains 17 chapters. Each chapter contains the following
subject matter and the designated range of related ICD-9-CM codes in parentheses:

Chapter 1 Infectious and Parasitic Diseases (001–139)

Chapter 2 Neoplasms (140–239)
Chapter 3 Endocrine, Nutritional and Metabolic Diseases, and Immunity
Disorders (240–279)
Chapter 4 Diseases of the Blood and Blood-Forming Organs (280–289)
Chapter 5 Mental, Behavioral and Neurodevelopmental
Disorders (290–319)
Chapter 6 Diseases of the Nervous System and Sense Organs (320–389)
Chapter 7 Diseases of the Circulatory System (390–459)
Chapter 8 Diseases of the Respiratory System (460–519)
Chapter 9 Diseases of the Digestive System (520–579)
Chapter 10 Diseases of the Genitourinary System (580–629)
Chapter 11 Complications of Pregnancy, Childbirth, and the Puerperium
(630–679)
Chapter 12 Diseases of the Skin and Subcutaneous Tissue (680–709)
Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue
(710–739)
Chapter 14 Congenital Anomalies (740–759)
Chapter 15 Certain Conditions Originating in the Perinatal Period (760–779)
Chapter 16 Symptoms, Signs, and Ill-Defined Conditions (780–799)
Chapter 17 Injury and Poisoning (800–999)

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Medical Coding and Billing Specialist

Each of the 17 chapters in Volume 1, Tabular List, contains the following subdivisions:
 Sections—Sections, are groups of three-digit categories that represent
a single disease entity or a group of similar or closely related conditions.
For example, in Volume 1 you’ll find that codes 001-009 represent the
category of Intestinal Infectious Diseases.

 Categories—Within sections, each three-digit category represents a

single disease entity or a group of similar or closely related conditions.
As you look at Intestinal Infectious Diseases (001-009) in Volume 1,
you’ll see categories such as 003 for Other salmonella infections and 004
for Shigellosis.

 Subcategories—Within categories, each fourth-digit subcategory

provides specific information regarding the cause of death or etiology,
site, or manifestation—the signs or symptoms of an illness. You
cannot assign a three-digit code if a category has fourth digits available.
You must assign the most specific code possible—the subcategory if it
is available. For example, you would use the four-digit code 003.1 for
Salmonella septicemia in Volume 1, the Tabular List.

 Fifth-Digit Subclassifications—A fourth-digit subcategory sometimes is

expanded to the fifth-digit level to provide more specific information. These
fifth-digit subclassifications, appear in four locations: at the beginning
of a chapter, at the beginning of a section, at the beginning of a three-digit
category, or in a four-digit subcategory. The fifth-digit subclassification
provides very specific information, such as the site of lymph nodes involved
in a diagnosis, and you must assign it if it is available. In Volume 1 you see a
fifth-digit code 003.21 for Salmonella meningitis.

 Residual Subcategories—These subcategories are codes with titles of

Other and Unspecified. Residual subcategories classify conditions that
are not assigned a separate subcategory. This ensures that a code can be
assigned for every disease. Residual subcategories titled Other often have
an 8 as the fourth digit; for example, 003.8 Other specified salmonella
infections. Residual subcategories titled Unspecified usually are assigned
the fourth digit of 9, for example, 003.9 Salmonella infection, unspecified.

Two supplementary classifications are provided in addition to the main classification

for diseases and injuries. These classifications contain alphanumeric codes, or
letters and numbers, whereas the other classifications only are numeric. These
supplementary classifications can be V codes or E codes.

Now let’s pause to reinforce your understanding of the organization of the ICD-9-CM.

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 Step 11 Practice Exercise 23-2

 Choose the best answer from the choices provided.

1. The ICD-9-CM for Physicians manual is divided into _____ volumes.

a. 12
b. two
c. three
d. 10

2. The ICD-9-CM for Physicians manual lists _____ codes.

a. fundamental
b. procedural
c. treatment
d. diagnostic

3. Main terms appear in _____ type.

a. italicized
b. boldface
c. underlined
d. Times Roman

4. Information in parentheses following a main term is called a(n)

_____, and it has no effect on selecting the correct code.
a. nonessential modifier
b. essential modifier
c. tabular reference
d. alphabetic code

5. The _____ uses a numerical index cross-referenced with diseases and

injuries according to the anatomical system affected and/or etiology.
a. Appendix
b. Glossary
c. Alphabetic Index
d. Tabular List

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Medical Coding and Billing Specialist

6. A medical coder must assign the most _____ code possible—a subcategory,
if it is available.
a. obvious
b. basic
c. specific
d. likely

7. Supplementary classifications might be _____ codes.

a. V or E
b. J or K
c. V or J
d. E or K

8. _____ classifications ensure that there is always a code for every disease.
a. Late effect
b. Residual
c. Supplementary
d. Rudimentary

 Step 12 Review Practice Exercise 23-2

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 13 Introduction to Coding Guidelines

 Near the beginning of your ICD-9-CM manual is a section
titled Coding Guidelines: ICD-9-CM Official Guidelines
for Coding and Reporting. This section contains coding
guidelines, conventions and chapter-specific guidelines. Take
a few moments to find this section in your manual. Remember
that there’s no need to memorize the guidelines—they will
always be available to you in your manual. However, it’s
important to know where to find this information and how
to use this resource. When you begin coding in upcoming
lessons, you will need to refer to these guidelines for
additional information regarding certain diseases and how to
code them.

There is no need to
memorize the guidelines,
as they will always be
available in your manual.

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The Coding Guidelines section begins with a Table of Contents that divides the
material into four parts. For now, focus on Section IV of the Coding Guidelines,
Diagnostic Coding and Reporting Guidelines for Outpatient Services. This section
includes specific guidelines for coding outpatient services. (Keep in mind that
outpatients are patients who do not stay overnight in a healthcare facility.)

The ICD-9-CM manual is printed each year before the guidelines are updated.
Therefore, the manual you have covers the previous year’s guidelines. For instance,
if you have the ICD-9-CM 2013 edition, you’ll find the 2012 guidelines.

This time gap means you must always be on the lookout for updated information as
it becomes available. The coding resources you just learned about will help you out!

Who Develops Diagnostic Coding Guidelines?

A team of four organizations is actively involved with in-depth coding principles
and practices. The groups include the Centers for Medicare and Medicaid
Services, or CMS; the National Center for Health Statistics; the American Health
Information Management Association, or AHIMA; and the American Hospital
Association, or AHA. These organizations cooperatively developed and approved
the “Diagnostic Coding and Reporting Guidelines for Outpatient Services,” which
is Section IV in your ICD-9-CM manual. The Editorial Advisory Board of the AHA
Coding Clinic publishes this document.

You will find references to the AHA in the Tabular List,

or Volume 1, under many code descriptions.

As you continue to become more familiar with your ICD-9-CM manual, you will
find references to the AHA in the Tabular List, or Volume 1, under many code
descriptions. Take a look at this example:

275.4 Disorders of calcium metabolism

AHA: 4Q, ’97, 33

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AHA: 4Q, ’97, 33 refers you to the AHA Coding Clinic for ICD-9-CM a publication
that discusses official advice concerning coding topics. It is a quarterly newsletter
published by the American Hospital Association. As a student, you do not need to
have access to this publication to complete this course, but we do want you to be
aware of these references.

Now let’s get familiar with the cross-reference terms you may encounter.

Cross-reference Terms
Volume 2, the Alphabetic Index to Diseases uses cross-reference terms to instruct
you to look in another place before you assign a code. These cross references provide
possible modifiers for a term or its synonyms. Follow the cross references to the
correct code when you don’t find the diagnosis under the first term you locate. The
following three types of cross reference terms are used: see, see also and the see
category. Before you look more closely at each term and its use, be advised that you
will be provided with examples to assist in understanding the ICD-9-CM’s meaning.
You might not have enough information to determine exact coding.

See
The see cross reference points you to another term. You will follow the see cross
reference to ensure that you assign the correct code to a diagnosis. The following
example from Volume 2 shows you how to use the see cross reference:
Roentgen ray, adverse effect—see Effect, adverse, x-ray
The see cross reference instructs you to go to Effect, adverse and go down the list of
subterms until you come to x-ray. This is what you will find:
Effect, adverse NEC
•
•
•
x-rays NEC 990
dermatitis or eczema 692.82

Cross references provide

possible modifiers for a
term or its synonyms.

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See Also
See also indicates that additional information about the term and code is available
under the referenced term in another place in the Alphabetic Index to Diseases. The
see also cross reference gives you an additional diagnosis and code when the main
term or subterm is insufficient. The additional information in the see also cross
reference helps you select the correct code, so follow this instruction to ensure coding
accuracy. Here’s an example from Volume 2 that includes the see also cross reference:
Tuberculoma — see also Tuberculosis
brain (any part) 013.2 
meninges (cerebral) (spinal) 013.1 
spinal cord 013.4 
When you go to the Tuberculosis main term, you will find a very
long list of subterms to review. You must determine whether any
of them is appropriate to include based on the diagnosis with
which you are working.
It’s also important to use multiple codes to identify all components of a
diagnosis when a single code does not fully describe a given condition.
The see also cross reference helps you do this. However, medical
record documentation must mention the presence of all the
elements of any code you use. Always ask the physician involved Always ask the physician
if you are unsure about assigning multiple codes. We will discuss involved if you are
multiple codes further in a moment. unsure about assigning
multiple codes.
See Category
The see category cross reference directs you to an additional three-digit category
in Volume 1, Tabular List. If the see category is included with a term, you cannot
assign the correct code unless you follow this instruction and read the applicable
notes in Volume 1. For example, in Volume 2 under the main term Hemiplegia
with a code of 342.9  , the subterm thrombotic (current), late effect, includes a
see category directing you to Late effect(s) (of) cerebrovascular disease:
Hemiplegia 342.9 
•
•
•
thrombotic (current) (see also Thrombosis, brain) 434.0 
late effect — see Late effect(s) (of) cerebrovascular disease

General adjectives, or descriptive words, such as acute and hereditary, appear

as main terms, usually with a cross reference to see conditions or see also. In
addition, if anatomic sites such as arm or neck appear as main terms, there will
be a cross reference to see conditions or see also.

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Includes and Excludes

The ICD-9-CM manual uses INCLUDES and EXCLUDES instructional notes to help
you assign diagnostic codes at the highest level.

The INCLUDES box appears immediately after a three-digit code’s title to provide
additional information regarding the category’s contents. The Tabular List uses inclusion
notes to define a category in greater detail. Look at the following example from Volume 1:
633 Ectopic pregnancy

INCLUDES ruptured ectopic pregnancy

The EXCLUDES box appears in a listing when terms are not to be coded under the
referenced term; such terms are listed somewhere else. A code reference is provided
in parentheses directing you to the correct term or area. The Tabular List uses
exclusion notes, and you can see them easily because EXCLUDES is printed in
reverse type with a box around it to define the category in greater detail. Look at the
following example from Volume 1:
711 Arthropathy associated with infections
•
•
•
EXCLUDES rheumatic fever (390)

Notes
Notes, which give coding instructions, appear in Volume 1, the Tabular List and in
Volume 2, the Alphabetic Index to Diseases of the ICD-9-CM manual. The length of
the notes varies. Depending on where the notes are located, their appearance also
varies. When notes are in Volume 2, they are boxed and italicized. Notes in Volume
1 are located at various levels of the classification system. The following examples
show some notes from different parts of the ICD-9-CM manual and how these notes
instruct you.

This note from Volume 2 gives you additional coding instructions and defines terms:
Injury 959.9

Note—For abrasion, insect bite (nonvenomous), blister, or scratch, see Injury, superficial.
For laceration, traumatic rupture, tear, or penetrating wound of internal organs,
such as heart, lung, liver, kidney, pelvic organs, whether or not accompanied by
open wound in the same region, see Injury, internal.
For nerve injury, see Injury, nerve.
For late effect of injuries classifiable to 850-854, 860-869, 900-919, 950-959, see
Late, effect, injury, by type.

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This note from Volume 1 instructs you to assign a fifth digit because
subclassification categories are available:
831 Dislocation of shoulder
EXCLUDES sternoclavicular joint (839.61, 839.71)
sternum (839.61, 839.71)
The following fifth-digit subclassification is
for use with category 831:
0 shoulder, unspecified
Humerus NOS
1 anterior dislocation of humerus
2 posterior dislocation of humerus
3 inferior dislocation of humerus
4 acromioclavicular (joint)
Clavicle
9 other
Scapula

Multiple Coding
Multiple coding simply means using more than one code to
identify a diagnosis as accurately as possible. Several instructional
phrases indicate that you are required to use multiple codes. The
following examples instruct you in multiple coding:

Use additional code if desired—Volume 1, the Tabular List

includes this notation, which instructs you to use an additional Multiple coding means
code to provide a more complete picture of the diagnosis or using more than one
procedure. You should ignore the words if desired—use additional code to identify a
codes when this multiple coding note is provided as long as the diagnosis as accurately
documentation supports the code. as possible.

When you see an instruction at the beginning of a chapter, that instruction applies
to all the codes in the chapter. Instructions also may appear at the beginning of a
section or a category. In the following example from Volume 1, the notation instructs
you to identify other aspects of the disease, such as manifestation, cause, associated
condition and nature of the condition.
358.2 Toxic myoneural disorders
Use additional E code to identify toxic agent

Code first underlying disease—This instruction identifies diagnoses that are not
primary (or principal) and are incomplete when they are used alone. Only Volume 1,
the Tabular List, uses this instruction. First, record the underlying disease, which
often is the second line in the code. Then record the primary disease or first line in
the code.

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Medical Coding and Billing Specialist

Look at the following example from Volume 1:

595.4 Cystitis in diseases classified elsewhere
Code first underlying disease, as:
actinomycosis (039.8)
amebiasis (006.8)
bilharziasis (120.0–120.9)
Echinococcus infestation (122.3, 122.6)

In this example, if amebiasis is documented as the underlying disease, you first

would code amebiasis (006.8), and then Cystitis in diseases classified elsewhere
595.4. You will code: 006.8 595.4

Connecting Words
Connecting words are words that connect main terms with subterms. These words
connect the terms and subterms to show that there is a relationship between the
main term and an associated condition or etiology. The following words are examples
of some connecting words used in Volume 2, the Alphabetic Index to Diseases:

associated with during secondary to

complicated (by) following with
due to in with mention of
of without

In the example that follows, the connecting terms are italicized to demonstrate their use:
883 Open wound of finger(s)
INCLUDES fingernail
thumb (nail)
883.0 Without mention of complication
883.1 Complicated
883.2 With tendon involvement

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 ICD-9-CM Coding Introduction

Abbreviations
The ICD-9-CM manual frequently uses the following two abbreviations with which
you need to be familiar:
 NEC—NEC means not elsewhere classifiable in the ICD-9-CM
manual. This abbreviation is to be used only when there is not enough
information available to code the term more specifically, even when a
diagnostic statement was very specific; and only with ill-defined terms
included in Volume 1, the Tabular List, to warn you that specified forms
of the condition are classified differently. In such cases, use NEC codes
only if more precise information is not available.

 NOS—NOS means not otherwise specified. Use NOS codes only when
the diagnosis statement does not provide enough information.

These abbreviations are for your reference only. You will not record them with the
assigned code.

Symbols
Symbols often are used in the ICD-9-CM manual to identify a code number that
is new since the previous edition of the manual. Symbols also might be used to
indicate a change in a code’s description. Diagnostic codes that require a fourth
or fifth digit are marked with a symbol. Some codes are marked to indicate a
footnote that is applicable to all subdivisions in the code.

We will be discussing, in detail, some of the symbols. In the front of your

ICD-9-CM manual, you will find more information about these symbols under
the heading Additional Conventions, Symbols and Notations. These symbols, just
like the abbreviations, are for your reference only and will not be recorded with
the assigned code.

Punctuation
The ICD-9-CM manual uses the following punctuation symbols:

 Parentheses ( )
Parentheses enclose supplementary information; this information
consists of words whose presence or absence in the statement of a disease
does not affect the code number. For example, in Volume 2, Alphabetic
Index to Diseases, erythroblastic anemia is included as supplemental
information, but the terms have no bearing on the code used:
Dameshek’s syndrome (erythroblastic anemia) 282.49

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Medical Coding and Billing Specialist

 Square Brackets [ ]
Brackets enclose synonyms, alternative wordings or explanatory
phrases. For example from Volume 1, the Tabular List, the bracketed
information—[and kyphoscoliosis]—is included for clarification:
737.3 Kyphoscoliosis and scoliosis
DEF: Kyphoscoliosis: backward and lateral
curvature of the spinal column; it is found in
vertebral osteochondrosis.

DEF: Scoliosis: an abnormal deviation of the

spine to the left or right of midline.

737.30 Scoliosis [and kyphoscoliosis],

idiopathic

 Slanted Brackets [ ]
Slanted brackets, or brackets that are italicized, appear in Volume 2,
Alphabetic Index to Diseases, to indicate that another code is required in
addition to the first code listed. You must record both codes in the order
they are given in the volume, but you will not include the slanted brackets
when recording the code. For example, in Volume 2, if the diagnosis is
diphtheritic epididymitis, you must code both the 032.89 and the
604.91—in that order:
Epididymitis (nonvenereal) 604.90
with abscess 604.0
•
•
•
diphtheritic 032.89 [604.91]

You will code: 032.89 604.91

 Colon :
Volume 1, the Tabular List, uses a colon after an incomplete term
that requires an adjective, or descriptor. For example, in Volume 1, if
hypostatic is included in the diagnosis without either of the terms below
it, hypostatic would not be listed under 514. See the example below:
514 Pulmonary congestion and hypostasis
Hypostatic:
bronchopneumonia
pneumonia
Hypostatic is a descriptor meaning congestion of blood in a part of
the body due to impaired circulation. Since hypostatic is an adjective
(descriptor), it must be followed by a noun identifying the etiology, or
cause of the conditon. Note: If the pneumonia were not hypostatic, it
would be coded differently.

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 ICD-9-CM Coding Introduction

 Braces }

Braces enclose a series of terms, each of which is changed by the

statement to the right of the brace. For example, in Volume 1:
755.2 Reduction deformities of upper limb
755.20 Unspecified reduction deformity of upper limb
Ectromelia NOS
of upper limb
Hemimelia NOS

A bullet indicates a new code.

A triangle in the Tabular List indicates that the code title has
been revised. In the Alphabetic Index the triangle indicates that
the code has been changed.

 These symbols appear at the beginning and at the end of a

section of new or revised text.

Coding Enhancements Included in the Ingenix ICD-9-CM System:

 This symbol indicates that additional digits are required and are found in
Volume 2, Alphabetic Index to Diseases.
DEF: This symbol indicates a definition of a disease. The definition will appear in
blue type in the Tabular List.
*****************************
In the Tabular List, the symbols listed below indicate when additional digits
are required:

4th This symbol indicates that the code requires a fourth digit.
5th This symbol indicates that the code requires a fifth digit.

More About Fourth- and Fifth-Digit Coding

The following example is found in Volume 2, Section 1, Index to Diseases:
Milk-leg (deep vessels) 671.4 
In the Index to Diseases, you will find a check box like this  at the end of some
codes to indicate that additional digits are required. As a medical coder, you will
look in Volume 1, the Tabular List, to choose the appropriate digits to complete the
assigned code.

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Medical Coding and Billing Specialist

When coding for diagnoses, always check codes in the Tabular List. A 4th
or 5th box in front of a three-digit code indicates that a fourth or fifth digit
is needed to complete the code. Fourth-digit codes are found within the three-
digit code category. Designated three-digit code categories include four digits,
so it is important to keep looking after you locate the three-digit code. Look at
this example taken from the Tabular List:
4th 331 Other cerebral degenerations
331.0 Alzheimer’s disease
5th 331.1 Frontotemporal dementia

Because code 331 has a 4th box located to the left, it cannot be used by itself. A code
from the codes listed in that category must be chosen for effective coding. Notice that only
the subclassification, 331.1-Frontotemporal dementia, requires a fifth digit. Once again,
you will code only the digits and not the symbols found in front of the codes.

An example of a fourth-digit subclassification box is found in the Tabular List at

the beginning of the section titled Other Pregnancy With Abortive Outcome
(634-639). This information guides you to use digits .0-.9 as fourth digits for code
categories 634-638. Within the ICD-9-CM manual, the boxed text is shaded in the
Tabular List.

Remember that fifth-digit subclassifications can be found in several areas of the ICD-9-CM
Volume 1, the Tabular List.

 At the Beginning of a Chapter

Take a look at Chapter 13 Diseases of the Musculoskeletal System
and Connective Tissue (710-739). Notice the shaded box just below the
chapter title that contains fifth-digit subclassifications 0-9. This area states
that we can use these digits for categories 711-712, 715-716, 718-719, and
730. Be sure to look back to the chapter beginning to see whether there are
fifth digits applicable to the codes that you are assigning.

 At the Beginning of a Section

Look in the Tabular List at Complications Mainly Related to
Pregnancy (640-649) in Chapter 11. This is a good example of fifth-digit
subclassifications being located at the beginning of a section. This
information tells us to use digits 0-4 with code categories 640-649.

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 ICD-9-CM Coding Introduction

 At the Beginning of a Three-digit Category

Locate category 715 Osteoarthrosis and allied
disorders in the Tabular List. Do you see the
shaded box after code 715 that includes the
fifth-digit subclassifications? These classifications
are for use with category 715 only. In coding a
diagnosis of osteoarthrosis of the shoulder, you
would select 715.9 Osteoarthrosis, unspecified
whether generalized or localized and add
the fifth-digit “1” for shoulder region, making a
complete code 715.91.

 In a Four-digit Subcategory
A shaded box after code
Look at this example taken from the Tabular List: 715 includes fifth-digit
4th 331 Other cerebral degenerations subclassifications.
331.0 Alzheimer’s disease
5th 331.1 Frontotemporal dementia
331.11 Pick’s disease
331.19 Other frontotemporal dementia
331.2 Senile degeneration of brain

Because there is a 4th box listed in front of code 331, medical coders know they must
choose a four-digit code from the Tabular List. As we mentioned earlier, code 331.1
has a 5th box in front of it. If you look at the indented codes under code 331.1, you
will find two choices: 331.11 Pick’s disease and 331.19 Other frontotemporal
dementia. If we were coding for Pick’s disease, we could not use 331.1 but
instead must use 331.11 for complete and accurate coding. Note, as well, that if
the condition was specified as frontotemporal dementia, without mention of Pick’s
disease, you would use the code 331.19.

By paying close attention to the enhancements in the Tabular List, you can
accurately locate the fifth-digit subclassification information to assign a fifth digit.

Not all codes have fourth or fifth digits, but when they are available, it is the
medical coding and billing specialist’s responsibility to include them for accurate
and specific coding.

Also noteworthy is the legend at the bottom of each page in the Tabular List.
Being familiar with the terms and symbols at the bottom of each page will help
you understand what you are reading in the Tabular List. Manuals may differ
according to publisher, but if you develop detective-type skills and look for all the
clues that are provided, you will do your best in the medical coding and billing field!

Once again, let’s review what you’ve learned about the conventions the ICD-9-CM
coding manual uses before you move on.

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 Step 14 Practice Exercise 23-3

 Choose the best answer from the choices provided.

1. When a diagnosis is not principal and is used alone, you should code the
_____ first.
a. primary disease
b. underlying disease
c. always secondary disease
d. usually secondary diagnosis

2. ICD-9-CM coding uses the INCLUDES and EXCLUDES instructional notes

to assist coders in assigning diagnostic codes at the _____ level.
a. lowest
b. median
c. highest
d. most obvious

3. Notes, when found in the Index to Diseases, are _____.

a. boxed and italicized
b. boldface and circled
c. boxed and boldface
d. underlined and highlighted

4. In the multiple coding instruction, “Use additional code, if desired,”

you should ignore the words _____.
a. use additional
b. additional code
c. use code
d. if desired

5. NEC means _____.

a. never ever code
b. not elsewhere classifiable
c. not enough classification
d. never endeavor coding

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 ICD-9-CM Coding Introduction

6. NOS means _____.

a. never occupied specialty
b. nine other subclassifications
c. not otherwise specified
d. not often subdivided

7. A note might instruct you to assign a(n) _____ digit because subclassification
categories are available.
a. third
b. fourth
c. additional
d. fifth

 Step 15 Review Practice Exercise 23-3

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 16 ICD-9-CM Terminology

 Many—if not most of—the terms used in the ICD-9-CM manual have other
definitions and meanings when they are used elsewhere. You need to be familiar
with terms that are used throughout the ICD-9-CM manual as they relate to
medical coding. This will help you code a medical diagnosis correctly.

The following definitions are specific to their use in the ICD-9-CM coding manual:
 Acute—Short and severe; for example, a new injury or disease.
 Adverse—Any unfavorable, unintended response to a drug that occurs
with proper dosage.
 Aftercare—A visit to the medical facility for something planned in
advance; for example, the removal of sutures (stitches).
 Chronic—To continue over a long period of time or recurring frequently.
 Concurrent—When a patient is treated simultaneously by more than
one physician for different care conditions.
 Foreign body—An object not naturally occurring in the human body.
 Late effect—A residual effect after the acute phase of an illness or injury
has ended.
 Manifestation—The characteristic signs or symptoms of an illness.
 Residual—The long-term conditions resulting from a previous acute
illness or injury.

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When both an acute disease and a chronic disease coexist and no single code exists
to code both diseases together, code the acute disease as the principal diagnosis
and the chronic disease as the secondary, or coexisting, condition. Here’s an
example. The physician documents acute and chronic thyroiditis. With the help
of your medical terminology knowledge, you can figure out that this condition is
inflammation of the thyroid gland. Now, look in your ICD-9-CM manual’s Index
to Diseases for thyroiditis. Then look for the subterms acute and chronic. You will
find codes 245.0 Acute thyroiditis and 245.8 Chronic thyroiditis. Go to the
Tabular List to verify these codes. You will code the acute condition first, listing
code 245.0, and then code 245.8.

A late effect is a residual condition that occurs after the acute

phase. Late-effect categories are three-digit categories, and they
can require additional digits. When you code a late effect you
generally assign two codes: the residual effect and the cause of the
late effect. Sometimes a late-effect code has been expanded to a
fourth or even fifth digit to include the manifestation or residual
effect, and only one code is needed. Remember when you code late
effects that there is no time limit between the acute phase and the
late effect. In other words, some period of time can pass between
the acute phase of a condition and the point at which the late
effect or residual condition is diagnosed.

Let’s also review two terms we talked about in previous lessons— The chief complaint is
chief complaint and diagnosis. You recall that the chief complaint the main reason a
is the main reason a patient sees a doctor. For example, if a patient sees a doctor.
patient tells a doctor that he has a sore throat, that is the chief
complaint. The diagnosis occurs when the doctor identifies what is
wrong with a patient. In our example, the doctor might examine
the patient and determine the patient has strep throat. This is
the diagnosis.

One last important term with which

you should be familiar is unconfirmed
diagnoses. You do not code conditions
when it is uncertain if they really exist. In
Chief complaint = main reason
for doctor visit other words, don’t code a condition until it
has been determined to be the diagnosis.
Diagnosis = physician’s identification
of what’s wrong with
Unconfirmed diagnoses are suspected
patient conditions, such as those that contain
words like suspicion of, probable or likely.

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It’s important that medical coders do not play doctor and narrow down the choices
of categories for the diagnosis. The concept of unconfirmed diagnoses affects how
insurance companies reimburse, so it is important that you understand it. We’ll
discuss how to deal with unconfirmed diagnoses later in your studies.

 Step 17 The Appendices

 Volume 1, the Tabular List of the ICD-9-CM manual contains four appendices.
(Prior to October 1, 2004, there were five. Appendix B no longer exists.) As a
group, these appendices provide additional information about the coding for a
patient’s diagnosis, further define a diagnostic statement, provide clarification
about new drugs and reference three-digit categories. Appendices are a good place
to look when you need detailed information about a specific topic. Specifically,
each appendix of the ICD-9-CM includes the following information.

Appendix A—Morphology of Neoplasms

Morphology is the study of neoplasms, or tumors. This appendix provides additional
detailed information about coding diagnoses in this category, such as types of tumors,
behavior of tumors and one-digit codes that are used to code neoplasms. The following
is an example entry from Appendix A:
M975 Burkitt’s tumor
M9750/3 Burkitt’s tumor
These codes are optional and are usually used for statistical information only. The
morphology codes will not be used in this course.

Appendix B—Glossary of Mental Disorders

This appendix was deleted October 1, 2004.

Appendix C—Classification of Drugs by AHFS List

This appendix is an alphabetized listing of drugs. A division of the
American Hospital Formulary Service, or AHFS, publishes a coded
listing of drugs. Appendix C is an alphabetized listing of those
drugs and their ICD-9-CM codes. The AHFS codes in this appendix
contain up to five digits and always begin with a number, followed
by a colon and up to four more digits to provide adequate detail.
The following is an example entry from Appendix C:
ICD-9-CM
AHFS List Diagnosis Code
28:04 General Anesthetics 968.4
gaseous anesthetics 968.2
halothane 968.1 Appendix C is an alphabetized
intravenous anesthetics 968.3 listing of drugs.

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Appendix D—Industrial Accidents According to Agency

This appendix contains three-digit codes to classify
occupational, or job-related, hazards. Seven categories
contain all the occupational categories. You often will use
these codes to track job-related causes of injury and death.
The following is an example entry from Appendix D:
1 MACHINES
11 Prime-Movers, except Electrical Motors
Appendix D codes are often 111 Steam engines
used to track job-related 112 Internal combustion engines
causes of injury and death. 119 Others

Appendix E—List of Three-Digit Categories

Appendix E contains a list of all the three-digit codes in the ICD-9-CM manual. These
codes are grouped by chapter to correspond with Chapters 1 through 17 of Volume 1, the
Tabular List, diagnostic codes. The following is an example entry from Appendix E:
LIST OF THREE-DIGIT CATEGORIES
1. INFECTIOUS AND PARASITIC DISEASES
Intestinal Infectious Diseases (001 – 009)
001 Cholera
002 Typhoid and paratyphoid fevers
003 Other salmonella infections
004 Shigellosis
005 Other food poisoning (bacterial)
006 Amebiasis
007 Other protozoal intestinal diseases
008 Intestinal infections due to other organisms
009 Ill-defined intestinal infections
Wow! We’re almost done with this lesson. Stop for a moment to review what you
learned about terminology and the ICD-9-CM manual’s appendices by completing
the following Practice Exercise.

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 Step 18 Practice Exercise 23-4

 Choose the best answer from the choices provided.

1. An object not naturally occurring in the human body is _____.

a. a foreign body
b. acute
c. chronic
d. a manifestation

2. A late effect is defined as a(n) _____ effect after the acute phase of an
illness or injury has ended.
a. aftercare
b. concurrent
c. chronic
d. residual

Match each appendix with the description of its contents.

3. _____ Appendix A a. Drug classification

b. Three-digit categories
4. _____ Appendix B
c. Study of tumors
5. _____ Appendix C d. Was deleted in 2004
e. Job-related accidents
6. _____ Appendix D

7. _____ Appendix E

 Step 19 Review Practice Exercise 23-4

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 20 The Steps to Correct Coding

 So how do you actually begin to assign codes? Well, one of the first sections you will
come across in the very beginning of the ICD-9-CM book is a section that outlines the 10
Steps to Correct Coding. Take a few moments to read these steps now.

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Now that you’re familiar with the steps provided in the ICD-9-CM book, let’s break
them down into the basics here. In later lessons, as you start to code, you will work
through the following steps:

Steps for Assigning Diagnostic Codes

1. Identify the main terms in the diagnostic
statement.
2. Locate each main term in the Index to Diseases
and read any notes that appear with the
main term.
3. Refer to any subterms indented under the main
term in the Index to Diseases.
4. Look at abbreviations, cross-references, symbols
and brackets.
5. Choose the tentative code you find in the Index to Diseases, Volume 2,
then locate and determine the highest level of specificity in the Tabular List,
Volume 1.
6. Read and use any instructional terms in the Tabular List as a
guide. Look for INCLUDES and EXCLUDES , notes and other
instructional comments at the beginning of each chapter. Also, look
at the three-digit code at the beginning of each category or group of
codes that you are using within the chapter and check for additional
instructions for the group.
7. Assign codes to their highest level of specificity, using the
following guidelines:
 Assign three-digit codes only when there are no four-digit
codes within that category.

 Assign a four-digit code only when there is no fifth-digit

subdivision for that subcategory.

 Assign a fifth-digit to the code for any subcategory for which a

fifth-digit subclassification is provided.

 Remember to continue coding the dictation until all conditions

have been fully identified before assigning the code.

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Outpatient Coding Tips

 If it is not documented, it did not happen.
 Do not assume anything.
 Terms such as possible, suspect, probable, rule out or consistent with
are not assigned codes.
 Code symptoms only when a definitive diagnosis is not documented.
 Check with the physician if the information is unclear.

Practice Makes Perfect

The key to diagnosis coding is to ask yourself a series of questions.
Let’s practice this process and the basic steps to coding. Take out your
ICD-9-CM manual and follow along with the coding examples listed
below. As you know from the basic steps to coding that you just learned,
each example begins in the Index to Diseases, or Volume 2, and is verified
in the Tabular List, or Volume 1. Don’t worry if you have a hard time
following this series of steps at first. In the next lesson, you’ll walk
through scenarios like this step-by-step as you begin to code on your own.
Asking a series of
Diagnosis: noncardiac chest pain questions is the key
What’s the main term? pain to diagnosis coding.
Where’s the pain? chest
What’s the type of pain? noncardiac
The Volume 2 coding pathway is pain, chest, noncardiac 786.59
Now turn to the Tabular List and verify the code description for 786.59.

Note: Because noncardiac chest pain was specified, code 786.59 Chest pain,
Other is used instead of an unspecified code. Trust the coding pathway you
found in Volume 2, Index to Diseases, to lead you to the correct code.

Diagnosis: sprained ankle

What’s the main term? sprain
Where’s the sprain? ankle
Does it include the foot? no
The Volume 2 coding pathway is sprain, ankle 845.00
Turn to the Tabular List and verify the code description
for 845.00.
Notice that the specific part of the ankle is not documented, and
so we code for unspecified site using the fifth-digit 0.

The main term for

sprained ankle is sprain.

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Diagnosis: diabetic cataracts

What’s the main term? cataracts
What’s the cause? diabetes
The Volume 2 coding pathway is cataract, diabetic 250.5  [366.41]

What does this boxed symbol mean? Turn to code 250.5 in the Tabular List.
You’ll note the fifth-digit subclassification box for the code category 250. In this
example, the type of diabetes is not specified, so the fifth digit would be 0. Now
let’s talk about the code in slanted brackets [366.41]. Remember that slanted
brackets mean you must use the code in those brackets, too. So in this example,
250.50 is the primary diagnosis, and 366.41 is the secondary diagnosis. When
you look up both these codes in the Tabular List, you’ll see that the code
descriptions are verified.

 Step 21 Pathways
 Remember that the key to diagnosis coding is to ask yourself a series of questions
once you have the documentation we discussed in previous lessons. The main
question is “What is the problem?” After you identify the problem or diagnosis, use
the main terms and subterms to locate the code in Volume 2 of the ICD-9-CM, as we
just discussed.

The coding pathway refers to the series of main terms

and subterms used to find the diagnostic code in that
manual. The main term is listed first, and then the
subterm. Think of a coding pathway as a road map
you would follow to arrive at your destination. To
what city are you going? What highway do you
follow, and what exit do you use to arrive at your
destination? So you see, a coding pathway is like a
road map to the correct code!

Let’s take a look at an example of a coding pathway. Think of a coding pathway as a

road map you would follow to
Aaron, age 7, presents with a fever and a pain in his right arrive at your destination.
ear. The doctor examines him, and this is her diagnosis:
otitis media, right ear.

You know the diagnosis is otitis media because the doctor has documented it in
the patient’s medical record. What do you look for first? Otitis is the main term.
Remember your medical terminology? Otitis means inflammation of the ear. It
is a medical condition. Media means middle, so now you know that media is the
subterm because it describes the location of the condition within the ear.

So the coding pathway for Aaron’s diagnosis is otitis, media. Following is a

sample entry from the ICD-9-CM that shows how this condition looks in
Volume 2.

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Volume 2 INDEX TO DISEASES

Othematoma 380.31

Otitic hydrocephalus 348.2

main term
Otitis 382.9
with effusion 381.4
acute 382.9
adhesive (see also Adhesions, middle ear) 385.10
chronic 382.9
diffuse parasitic 136.8
externa (acute) (diffuse) (hemorrhagica) 380.10
insidiosa (see also Otosclerosis) 387.9
interna (see also Labyrinthitis) 386.30
subterm media (hemorrhagic) (staphylococcal) (streptococcal) 382.9

Well done! Let’s take a look at some clinical applications of the coding rules.

 Step 22 Clinical Applications of Coding Rules

 As a medical coding and billing specialist, you are something of a translator. You
will take diagnoses and translate them into medical codes. To do that, you must
understand small but significant differences that you might find as you code. In
addition, you must know the rules of coding to accurately assign specific codes.
Knowing how to properly sequence and report diagnostic codes is your goal.

Let’s consider some clinical applications of coding rules. As you

deal with the bulleted situations that follow, be aware of the rules
that accompany them.
 Physician Coding—When you code a physician’s
diagnosis of a patient’s condition, the principal or primary,
diagnosis is the most important because it reflects the
current and most significant reason a patient seeks
treatment. You assign secondary codes to coexisting
diseases and conditions after you code the primary
diagnosis. Remember that when you assign a code for a pre-
existing condition, you must ensure that the diagnostic code
When you code a physician’s
identifies the current reason for medical care. Do not assign
diagnosis, the principal or
codes for rule-out statements such as probable, possible,
primary diagnosis is the
questionable, rule out and suspected in outpatient settings.
most important.

0205502LB03A-23-13 23-37
Medical Coding and Billing Specialist

 Common Coding for Outpatients and

Inpatients—You will assign codes for the
principal outpatient or principal inpatient
diagnosis and sequence the codes in the
correct order. Use the appropriate coding rules
and guidelines that you are learning. The
following tips will be helpful to remember:

1. Assign codes in the order of importance.

The order in which the doctor writes
the diagnosis might not determine the You will assign codes for the principal
main diagnosis. Determine the correct outpatient or principal inpatient diagnosis and
diagnosis order before you list the codes. sequence the codes in the correct order.
As the coder, you sometimes will not be
able to determine the principal diagnosis
and might have to ask the doctor.
2. Assign unspecified or other specified codes when the reason a patient
seeks healthcare is not clarified. For example, use unspecified codes when
the diagnosis has not been finalized. Use other specified codes when a
diagnosis has been made and there is no code to identify the diagnosis
more specifically.
3. Assign coexisting condition codes as supplementary diagnoses codes in order
of importance after you assign the principal diagnosis code. The order of
importance might be based in part on the time it takes to complete the
patient’s health care and on the resources that are used for each relevant code.

Inpatients and Outpatients

Even though you are already familiar with the terms
inpatient and outpatient, let’s talk about them in
greater detail here. An inpatient is someone
admitted to the hospital to stay overnight.
People who come to the hospital for an
x-ray or laboratory test are referred to as
outpatients. These are patients who are
receiving ancillary services—they come to
the hospital to receive the medical service
or treatment, and then they go home the
same day. Outpatients include patients who
go to the hospital for outpatient surgeries
or procedures, IV therapies or ED visits.
An inpatient is someone admitted to the Outpatients also are patients at doctors’
hospital to stay overnight. offices and other outpatient facilities such as
MRI centers, outpatient surgery centers and
chemotherapy or dialysis specialty clinics.

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 ICD-9-CM Coding Introduction

This is an example of what makes your job as a medical coding and billing
specialist so important! When a patient is admitted for surgery at a hospital,
he receives two bills. One is from the hospital, and one is from the surgeon. The
surgeon’s medical coding and billing specialist assigns codes for the diagnosis
the surgeon gave and the procedure she performed for the inpatient. Then
the claim form is sent to the patient’s insurance company for reimbursement.
The services that a patient uses while he is in the hospital, such as the room
charge, the operating room and any medications received, are charged and
coded by the hospital inpatient medical coding and billing specialist.

Now, let’s pause to complete a Practice Exercise.

 Step 23 Practice Exercise 23-5

 Choose the best answer from the choices provided.

1. The first step in ICD-9-CM coding is to identify all _____.

a. Tabular Lists
b. Alphabetic Indexes
c. main terms
d. three-digit codes

2. Assign codes to their _____ level of specificity.

a. individual
b. highest
c. diagnostic
d. subclassified

3. When you assign codes for an outpatient or inpatient diagnosis, the

_____ is the first code sequenced.
a. coexisting condition
b. unspecified code
c. principal diagnosis
d. questionable diagnosis

4. Do not assign codes for _____ statements in outpatient settings.

a. rule-out
b. line-in
c. opt-out
d. add-in

0205502LB03A-23-13 23-39
Medical Coding and Billing Specialist

For the following items, fill in the blanks as directed.

5. Urinary tract infection

Main term __________________________________
Subterm __________________________________
Coding pathway __________________________________

6. Recurrent appendicitis
Main term __________________________________
Subterm __________________________________
Coding pathway __________________________________

7. Unknown pain in leg

Main term __________________________________
Subterm __________________________________
Coding pathway __________________________________

8. Diaper rash
Main term __________________________________
Subterm __________________________________
Coding pathway __________________________________

9. Loss of appetite
Main term __________________________________
Subterm __________________________________
Coding pathway __________________________________

10. Inflammation of the sinus

Main term __________________________________
Subterm __________________________________
Coding pathway __________________________________

11. High-altitude sickness

Main term __________________________________
Subterm __________________________________
Coding pathway __________________________________

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 ICD-9-CM Coding Introduction

12. Vision examination

Main term __________________________________
Subterm __________________________________
Coding pathway __________________________________

13. Ear examination

Main term __________________________________
Subterm __________________________________
Coding pathway __________________________________

 Step 24 Review Practice Exercise 23-5

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made. If you have questions, review your lesson material,
then contact your instructor.

 Step 25 Lesson Summary

 Think of how much you’ve already learned about diagnostic coding! You understand
how each volume is organized, and you have a firm grasp of the content of each
section, appendix and chapter. This lesson also taught you about the numerous
conventions of the ICD-9-CM. We covered a lot of information here, so if you found
any of it confusing, go back and reread the lesson step(s) that you found difficult to
understand. And remember, your instructor is available to answer your questions!

In addition to what you’ve learned in this lesson, you have seen a lot of examples of
actual medical codes. Although looking at all of these codes might have been a bit
intimidating at first, remember, just as is true of the ICD-9-CM, the more you see
these codes and study their uses, the more familiar they will become to you. Before
you know it, you’ll be using these codes without thinking twice as you embark on
your new career as a medical coding and billing specialist!

0205502LB03A-23-13 23-41
Medical Coding and Billing Specialist

 Step 26 Mail-in Quiz 23

 Follow the steps to complete the Quiz.

a. Be sure you’ve mastered the instruction and the Practice Exercises that
this Quiz covers.
b. Mark your answers on your Quiz. Remember to check your answers with the
lesson content.
c. When you’ve finished, transfer your answers to the Scanner Answer Sheet
included. Use only blue or black ink on your Scanner Answer Sheet.
d. Important! Please fill in all information requested on your Scanner Answer
Sheet or when submitting your Quiz online.
e. Submit your answers to the school via mail, fax or, to receive your grade
immediately, submit your answers online at www.uscareerinstitute.edu.

Mail-in Quiz 23
Each item is worth 2.5 points.

Choose the best answer from the choices provided.

1. ICD stands for _____.

a. Instructional Classification of Diseases
b. International Class of Diagnoses
c. Instructional Classification of Diagnoses
d. International Classification of Diseases

2. In ICD-9-CM, CM stands for _____.

a. Coding Modification
b. Clinical Medicine
c. Clinical Modification
d. Coding Main Terms

3. _____ today is used to facilitate payment of medical services and study

the cost of health care.
a. Insurance
b. Coding
c. Medicine
d. Billing

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 ICD-9-CM Coding Introduction

4. The ICD coding system appeared in the United States in the _____.
a. 1700s
b. 1600s
c. 1900s
d. 1800s

5. Which of the following is NOT one of the reasons that the number of
people who go to the doctor has increased? _____
a. People are living longer and require more health care.
b. The cost of health care has decreased.
c. Technological advances offer more options for better health care.
d. People have better access to health care than ever before.

6. _____ published Natural and Political Observations Made upon the Bills
of Mortality in 1662.
a. William Farr
b. Bill London
c. John Graunt
d. Bill Graunt

7. The _____ is the directing and coordinating authority for health

within the United Nations system.
a. World Heath Organization (WHO)
b. General Register Office of England and Wales
c. International Statistical Institute
d. International Statistical Congress

8. The International Statistical Classification of Diseases and Related

Health Problems, 10th Revision (ICD-10) was released in ______.
a. 1989
b. 1994
c. 1979
d. 2000

9. _____ was the first medical statistician.

a. Jesus E. Monjaras
b. Dr. Jacques Bertillon
c. John Graunt
d. William Farr

0205502LB03A-23-13 23-43
Medical Coding and Billing Specialist

Determine which code set applies to each description.

10. Lacks laterality _____

a. ICD-9-CM
b. ICD-10-CM

11. Codes are 3 to 7 characters in length _____

a. ICD-9-CM
b. ICD-10-CM

12. Flexible for adding new codes _____

a. ICD-9-CM
b. ICD-10-CM

13. Difficult to analyze data due to nonspecific codes _____

a. ICD-9-CM
b. ICD-10-CM

14. Detail improves the accuracy of data used in medical research _____
a. ICD-9-CM
b. ICD-10-CM

15. Limited space for new codes _____

a. ICD-9-CM
b. ICD-10-CM

16. First digit may be alpha or numeric _____

a. ICD-9-CM
b. ICD-10-CM

17. Has laterality _____

a. ICD-9-CM
b. ICD-10-CM

18. Specificity improves coding accuracy and depth of data for

analysis_____
a. ICD-9-CM
b. ICD-10-CM

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 ICD-9-CM Coding Introduction

19. Supports interoperability and the exchange of healthcare data among

other countries and the United States _____
a. ICD-9-CM
b. ICD-10-CM

20. Approximately 15,000 codes _____

a. ICD-9-CM
b. ICD-10-CM

Choose the best answer from the choices provided. Refer to your ICD-9-CM manual
when needed.

21. The Index to Diseases of the ICD-9-CM is in Volume _____.

a. 1
b. 2
c. 3
d. 4

22. Volume 1 of the ICD-9-CM is called the _____.

a. Alphabetic Index
b. Tabular List
c. E Codes List
d. Subsection

23. The codes in ICD-9-CM Volume 1 for Infectious and Parasitic Diseases
are contained in Chapter _____ and range from 001–139.
a. 2
b. 4
c. 11
d. 1

24. The codes in Volume 1 for Diseases of the Digestive System are contained
in Chapter 9 and range from _____.
a. 629–670
b. 520–579
c. 400–429
d. 570–599

0205502LB03A-23-13 23-45
Medical Coding and Billing Specialist

25. Codes ranging from 680–709 cover _____.

a. diseases of the blood and blood-forming organs
b. diseases of the respiratory system
c. complications of pregnancy
d. diseases of the skin and subcutaneous tissue

26. The three types of cross-reference terms are _____.

a. see also, refer to, see category
b. see, see also, see category
c. refer to, glance at, always note
d. glance at, always note, see

27. Suspected conditions are also known as _____.

a. acute conditions
b. recurrent diagnoses
c. unconfirmed diagnoses
d. recurrent conditions

Match each symbol with the correct description.

28. _____ 4th 5th a. Used in the Tabular List after an

incomplete term that requires an
29. _____ Colon : adjective or descriptor, which follows it,
to be assignable to the category
30. _____ Braces } b. Needs additional digit
c. Enclose a series of terms, each of which
is changed by the statement appearing to
the right

Match each symbol with the correct description.

31. _____ Parentheses ( ) a. Used in the Index and indicate the need
for another code in addition to the first
32. _____ Slanted Brackets [ ] code listed
b. Enclose synonyms, alternative wordings
33. _____ Brackets [ ] or explanatory phrases
c. Enclose supplementary information

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 ICD-9-CM Coding Introduction

Match each word with the correct definition.

34. _____ Aftercare a. Treatment for a patient being treated

simultaneously by more than one physician
35. _____ Concurrent b. A visit for something planned in advance
c. The long-term conditions resulting from a
36. _____ Residual previous acute illness or injury

Match the disease, system or condition with its correct chapter in the Tabular List.

37. _____ Neoplasms a. Chapter 9

b. Chapter 2
38. _____ Circulatory system
c. Chapter 7
39. _____ Digestive system d. Chapter 13

40. _____ Connective tissue

0205502LB03A-23-13 23-47
Medical Coding and Billing Specialist

Congratulations!
You have completed Lesson 23.

Learn
ing
Skillful
Ac
co Terrific
mp
lis
hm
Drive en
t!
Quality

Do not wait to receive the results of your Quiz

before you move on.

23-48 0205502LB03A-23-13
 Lesson 24

Introduction to
ICD-9-CM
Medical Coding—
Terminology:
FromWord
Infections
Parts to
Blood Diseases
 Step 1 Learning Objectives for Lesson 24
 When you have completed the instruction in this lesson, you will be trained to do the following:
 Define and provide examples of the following:
 infectious and parasitic diseases
 neoplasms
 endocrine diseases
 nutritional diseases
 metabolic diseases
 immunity disorders
 diseases of the blood and blood-forming organs.

 Apply the rules related to Chapters 1 through 4 of the Tabular List in the
ICD-9-CM manual.

 Identify the diagnoses, outline the coding pathway and assign the final code
for the documented disorders and diseases.

 Step 2 Lesson Preview

 Now that you understand the format and conventions of the ICD-9-CM you’re ready
to learn the functions of the manual. In the next few lessons, we’re going to group
the information from each of the chapters in Volume 1 of the ICD-9-CM manual,
the Tabular List, and show you how to code some of the subject matter included in
each chapter. This lesson covers the contents of Chapters 1 through 4: Infectious and
Parasitic Diseases; Neoplasms; Endocrine, Nutritional and Metabolic Diseases, and
Immunity Disorders; and Diseases of the Blood and Blood-forming Organs.

0205502LB03A-24-13
Medical Coding and Billing Specialist

The material in this lesson might seem like a lot of information, but don’t worry.
You may ask yourself, “Why are we starting with the information in the Tabular
List, Volume 1, when we’ve been taught to begin our search for codes in the
Alphabetic Index to Diseases, Volume 2”? Because the Tabular List is organized
numerically, it will be easier to discuss each disease category as they are listed
in the 17 chapters. We’ll work through everything methodically and give you
plenty of practice along the way. For example, each chapter of the ICD-9-CM
manual is divided into sections. Each section contains a group of closely related
conditions, or categories. We will define each section for you and show you the
important references in the Tabular List. Then you will begin the step-by-step
process of diagnostic coding for sample dictations and scenarios!

Keep one thing in mind as you code the practice exercises and scenarios
throughout the following ICD-9-CM coding lessons: for now, we are
focusing only on ICD-9-CM codes—not CPT (or procedure) codes. You
will see physician notes and documentation about specific procedures in
some of the scenarios we use just because we want you to practice with
authentic examples. But remember that you will code only the diagnoses
during these lessons. You will have plenty of time and lots of practice
combining procedural and diagnostic codes in later lessons, after you’ve
become more familiar and comfortable with the ICD-9-CM codes.

By the time you finish these diagnostic coding lessons, you’ll be using your
ICD-9-CM book with ease and confidence! You’ll know where to look when you
need assistance as you code, and you’ll have these materials to use as a reference
tool during the remainder of the course and in your career as a medical coding and
billing specialist. So, get ready... Get set... Let’s code!

Get ready . . . Get set . . . Let’s code!

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 ICD-9-CM Coding—From Infections to Blood Diseases

 Step 3 Infectious and Parasitic Diseases (001-139), Part 1

 Infectious and parasitic diseases generally are caused by a bacterium, virus, fungus
or animal parasite. Occasionally, their cause also may be unknown. These infections
can be transmitted from a host organism, or they simply can be created within the
human body. Some examples of infectious and parasitic diseases discussed in this
chapter are food poisoning, bubonic plague, HIV, warts and thrush.

Let’s start by opening your ICD-9-CM manual to the Tabular List at the beginning
of the “Infectious and Parasitic Diseases” chapter. At the top of the page, just under
the chapter title, you will see a note. Remember what you learned about notes in
Lesson 23? The note here in Chapter 1 indicates that you will find the categories for
late effects of infectious and parasitic diseases in codes 137 through 139. Below the
note, you see INCLUDES . This informs you that you will find diseases generally
recognized as communicable or transmissible, and a few diseases of unknown
but possibly infectious origin, in this chapter. Below the INCLUDES you’ll find
EXCLUDES . The EXCLUDES directs you to other codes for diseases that are not
included within this chapter.

One final note on locating codes for this chapter: If, from the dictation you receive,
you have trouble finding the main term of a diagnosis in the Index to Diseases, turn
to the main term Infection. The diseases in this chapter are infections, so that is a
great place to start when you find yourself stuck! An example of this is Staphylococcus
aureus. You will not locate the correct code by using Staphylococcus as the main term.
Use Infection as the main term in the Index to Diseases. The subterms staphylococcal
and aureus will lead you to the correct code for this condition.

Now that you have a bit of information about the “Infectious and Parasitic Diseases”
chapter, let’s move on to the first section. In each section, we’ll provide you with
examples so you can see how the codes fall into place.

Intestinal Infectious Diseases (001-009)

Intestinal infectious diseases are located in the intestine. Infectious organisms
or parasites cause diseases, which include cholera, shigellosis, food poisoning,
Escherichia coli (E. coli) and infectious diarrhea.

Take a look at the section “Intestinal Infectious Diseases (001-009)” in your ICD-9-CM
book, and see what information is provided. Remember to look for inclusions, exclusions
and additional notes to assist you in assigning accurate codes. In this case, you see by
the EXCLUDES under the subheading mentioned above, that codes in the 001-009
section are not to be used if you are coding helminthiases.

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Medical Coding and Billing Specialist

Let’s look at a few diseases and the information available in Chapter 1 to assist you
as you code. Turn to code 005 Other food poisoning (bacterial). The EXCLUDES
informs you that if you code food poisonings caused by salmonella infections,
you use codes 003.0 through 003.9. Now turn to code 008 Intestinal infections
due to other organisms. You see that this category INCLUDES any condition
classifiable to 009.0 through 009.3 with mention of the responsible organisms.
Code 008 EXCLUDES food poisoning by diseases with the codes 005.0 through
005.9. If you turn to codes 005.0 through 005.9, you see that those diseases include
staphylococcal, botulism, C. welchii, Clostridia, Vibrio parahaemolyticus, other
bacterial food poisonings and unspecified food poisoning. Are you starting to see the
importance of the information the ICD-9-CM manual provides as you code?

Now, put your ICD-9-CM manual to work. Let’s say a

patient is diagnosed with Salmonella septicemia. To
begin your search for the accurate code, start with the
Index to Diseases in Volume 2 and work through those
basic coding steps presented in the previous lesson.
To find the main term, remember to ask yourself,
“What is the problem?” The problem is septicemia, so
locate Septicemia in the alphabetical index. Next, ask
yourself, “What type of septicemia does the physician
say it is?” If you answered Salmonella, you’re on
the right track! Under Septicemia in the index, find
Salmonella. The Index to Diseases indicates the
tentative code is 003.1.

But you’re not done yet! Remember, this code is only

a tentative code. Once you find the code in the Index
to Diseases, you must always look up that code in the
To find the main term, Tabular List to determine the highest level of specificity.
remember to ask yourself, The Tabular List is organized numerically, so you
“What is the problem?” just need to locate 003.1. The description provided in
the Tabular List for 003.1 is Salmonella septicemia.
There are no inclusions, exclusions, additional digits or
notes provided. Therefore, you will assign code 003.1
Salmonella septicemia for the diagnosis.

Tuberculosis (010-018)
The second section in Chapter 1 of the Tabular List is “Tuberculosis (010-018).”
Tuberculosis is an infectious disease caused by the genus Mycobacterium. At one
time, tuberculosis was one of our society’s most deadly diseases, but the invention
of new drugs has steadily decreased the spread of this disease since the 1950s.
Nevertheless, the illness still afflicts nearly 25,000 Americans every year, most
of whom have lung disease. Tubercles, or small, rounded lesions and tissues
that begin to resemble cheese are a couple of the characteristics of the disease.
Tuberculosis can affect any organ, although the disease usually is found in the lung.

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 ICD-9-CM Coding—From Infections to Blood Diseases

What does the Tabular List tell us about

1
tuberculosis? Let’s take a look. The section
“Tuberculosis (010-018)” INCLUDES
infection by Mycobacterium tuberculosis
(human) (bovine). It EXCLUDES
congenital tuberculosis (771.2) and late
effects of tuberculosis (137.0-137.4). Do
you see a shaded box similar to this one?

This boxed information indicates that all

codes in the 010 through 018 range require a
fifth-digit subclassification. This means that
if you submit 011.0 as a code for infiltrative
pulmonary tuberculosis, the code is
invalid because a fifth digit is required. You
will need to use the boxed chart to determine
the final digit.

Now let’s use the following dictation to

practice what you’ve just learned:

Pathology Report
CHIEF COMPLAINT: Productive cough, rule out tuberculosis

LABORATORY FINDINGS: Sputum was positive for AFB

by microscopy. PPD was positive. Hct 25, MCV 72, total
protein 5.8; iron studies pending

IMPRESSION: Miliary tuberculosis

Your first step is to determine the main term, and then locate that term in the Index
to Diseases. The condition is tuberculosis, so locate that term in the index. What type
of tuberculosis is it? It is miliary tuberculosis. The answers to these questions tell
you the coding pathway in the index is Tuberculosis, miliary.

The tentative diagnostic code indicated is 018.9  . However, you know that if
you stop here, your code is invalid. Turn to the Tabular List to determine the
highest level of specificity. Locate code 018.9 in the Tabular List, then look to the
beginning of the category, which provides you with the information for the fifth-digit
subclassification. The dictation indicates that the tuberculosis was found in the
sputum by microscopy, which means 3 is the correct fifth digit. Therefore, the
code you assign for the diagnosis of miliary tuberculosis found in the sputum by
microscopy would be 018.93 Miliary tuberculosis, unspecified, tubercle bacilli
found (in sputum) by microscopy.

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Medical Coding and Billing Specialist

Zoonotic Bacterial Diseases (020-027)

The next section in the “Infectious and Parasitic Diseases” chapter is “Zoonotic
Bacterial Diseases (020-027).” Zoonotic bacterial diseases are transmitted from
animal to person under natural conditions. Diseases in this section include the plague,
deerfly fever and anthrax. The bubonic plague is the most common, acute and severe
form of the plague characterized by lymphadenopathy, chills, fever and headache.

Other Bacterial Diseases (030-041)

The section “Other Bacterial Diseases (030-041)” covers leprosy, diphtheria,
whooping cough, scarlet fever, tetanus and septicemia. In this section, you will
find an EXCLUDES that directs you to use codes 098.0 through 099.9 if you
are coding bacterial venereal diseases. The EXCLUDES also indicates that
you are to use code 088.0 if you are coding bartonellosis.

Locate 033 Whooping Cough in the Tabular List. Do you see the note to use an
additional code to identify any associated pneumonia? This means that if whooping
cough is documented with pneumonia in the dictation you receive, you must code
the pneumonia, as well. You will find similar directions under code 041 Bacterial
infection in conditions classified elsewhere and of unspecified site. The note
informs you that this category is provided for use as an additional code to identify
the bacterial agent in diseases classified elsewhere. You will also use this category
to classify bacterial infections of unspecified nature or site. As you continue reading,
you will see that septicemia is excluded.

Let’s try an example. As a medical coding and billing

specialist, you must code laryngeal diphtheria. As usual,
you begin in the Index to Diseases with the main term
Diphtheria. The subterm is laryngeal, the type of diphtheria.
The coding pathway of diphtheria, laryngeal indicates 032.3
as the tentative code. Turn to the Tabular List and locate
032.3 to determine the highest level of specificity. Based on
the information here, you will assign the ICD-9-CM code
032.3 Laryngeal diphtheria.

Septicemia is a systemic infection associated with

organisms in the bloodstream. Symptoms of septicemia
include fever, malaise and, possibly, impaired organ function.
Septicemia is treated with antibiotics and fluid hydration. It Septicemia is treated
is a serious condition that could lead to death. with antibiotics and
fluid hydration.
What information does the ICD-9-CM manual provide about
septicemia? In the Tabular List, code category 038 states to use
an “additional code for systemic inflammatory response syndrome
(SIRS) (995.91-995.92).” This general statement requires some
more detail for accurate coding, and you will find that information
in the guidelines in the front of your ICD-9-CM manual.

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 ICD-9-CM Coding—From Infections to Blood Diseases

As you see in the Tabular List, category 038 codes for septicemia. In most cases, you
will use code 038 in conjunction with code 995.9  . However, sepsis or SIRS must
be documented for you to use the 995.9  code. Let’s look at some examples for a
better understanding of when you need to apply the additional code, and when it is
not necessary.

Streptococcal septicemia. The coding pathway is Septicemia, streptococcal,

which you use to locate the tentative code of 038.0. You then turn to the Tabular
List to verify the highest level of specificity for this code. The note indicates to use
an additional code for SIRS. But SIRS or sepsis is not documented; therefore, you
will assign 038.0 Streptococcal septicemia as the only code for this diagnosis.

Streptococcal sepsis. This is a challenging diagnosis to code because the pathway

is not straightforward and requires some knowledge about the disease. Sepsis
occurs when there is a breakdown of local defense barriers, which permits the spread
of an infection, or absorption of toxic materials. Sepsis may be seen as cellulitis,
lymphangitis, lymphadentitis or septicemia. So septicemia is a form of sepsis. If
the physician documents streptococcal sepsis, you will code 038.0 Streptococcal
septicemia in conjunction with the SIRS (Systemic inflammatory response
syndrome) code 995.91.

Although we won’t focus on the codes in Chapter 17 for awhile, you will find it
helpful to familiarize yourself with code 995.9 in the Tabular List now. Take a
look at the five-digit code 995.91 from above, together with its detailed description:
995.91 Systemic inflammatory response syndrome (SIRS), Sepsis.

Human Immunodeficiency Virus (HIV) Infection (042)

HIV is a virus that can be separated into two stereotypes: HIV-1 and HIV-2.
HIV is the cause of acquired immunodeficiency syndrome, or AIDS. HIV-1 is
found worldwide, while HIV-2 is largely confined to West Africa. As its name
implies, AIDS is a syndrome (a mixture of symptoms) that results from severe
immunodepression caused by the human immunodeficiency virus (HIV). AIDS is
the profound depression of cell-mediated immunity that affects patients with a wide
variety of backgrounds.

HIV cannot survive outside of human cells, and humans are the only source of HIV
infection. HIV is transmitted from one person to another by close contact that allows
for the transfer of body fluids.

AIDS affects almost all organs of the body. Because the body can no longer fight
infection or organ disease, AIDS victims eventually become ill with cancer,
pneumonia and many other diseases. AIDS is a prime example of the body’s immune
system malfunctioning to the point that all organs eventually become affected, as
the following figure shows.

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Medical Coding and Billing Specialist

CENTRAL NERVOUS
SYSTEM
meningitis
encephalitis
AIDS dementia

LYMPH NODES
MOUTH lymphadenopathy
herpes labialis
thrush
TUMORS
lymphoma
LUNG
pneumonia

AIDS nephropathy
SMALL
INTESTINE
malabsorption

LARGE
INTESTINE Kaposi’s
colitis sarcoma
proctitis
SKIN
dermatitis
folliculitis
impetigo

Body
Figur sites
e 10-7: commonly affected
bodysitescommonl by AIDS
y affectedbyAIDS

ICD-9-CM Guidelines for HIV

Following are some rules to keep in mind when coding HIV and AIDS. They are
taken from the Coding Guidelines, C. Chapter-Specific Coding Guidelines in
the front on the ICD-9-CM manual. Be sure to review these guidelines in detail
when you use code 042 for any patient. The guidelines also discuss code V08 for
asymptomatic HIV. We will discuss V codes in a later lesson, but be aware that this
is an important code when coding for patients who have tested positive for HIV but
are currently showing no symptoms of the disease.
 Code only confirmed cases of HIV infection or illness stated by a
physician. In other words, if the physician does not document HIV as a
definite diagnosis, then you cannot code for it.

 When a patient is treated for an HIV-related condition or infection, code

042 as the principal diagnosis, followed by additional codes for related
diagnoses. Many conditions can be related to HIV such as pneumonia or
thrush. If the patient has an HIV-related condition, you must use code
042 as the principal diagnosis code and then code for the condition.

 When an HIV patient is being treated for an unrelated condition (e.g.,

fracture of ankle), code that condition as the principal diagnosis. Then
code 042 as an additional diagnosis to identify the patient’s HIV status. In
the example given, the fractured ankle is unrelated to the HIV infection.
The fracture is the reason the patient is being treated, so the code for the
fractured ankle is listed as the principal diagnosis, and the HIV status is
coded as a secondary diagnosis.

24-8 0205502LB03A-24-13
 ICD-9-CM Coding—From Infections to Blood Diseases

 Use V08 Asymptomatic human immunodeficiency virus [HIV]

infection status for patients with no documented symptoms but with
a positive HIV test result. You will not use code V08 if AIDS is already
documented or if the patient has any HIV-related illnesses. Once a
patient has had documented symptoms of HIV, V08 cannot be used again.

 Code 795.71 Nonspecific serologic evidence of human

immunodeficiency virus [HIV] for patients with inconclusive HIV
serology but no definitive diagnosis or manifestations of the illness. Use
this code only if test results are inconclusive and HIV has not been given
as a definitive diagnosis.

 Once a patient has been coded 042, you must use this code on every
following visit. You cannot assign 795.71 or V08 to that patient again.

Now take a look at the following dictation and consider how you would code the
diagnosis if you were the medical coding specialist in this clinic.

SUBJECTIVE
A 24-year-old established patient is seen at the clinic for 2-week history of
flu-like symptoms, including fever, headache, and tiredness. Patient history
indicates weight loss and an enlarged lymph node x 3 months. Social history
of intravenous drug abuse.

OBJECTIVE
After a comprehensive examination, HIV antibody and Western blot tests
were ordered.

ASSESSMENT
Symptoms are consistent with HIV. Results of the HIV antibody and Western
blot tests confirm the patient is HIV positive.

PLAN
The patient is provided a prescription for Retrovir.

Once again, use your ICD-9-CM manual to practice. You know the problem is that
the person has an infection. The type of infection is HIV, and the virus is showing
symptoms. Locate the main term Infection in the Index to Diseases, followed by the
subterm HIV.

If you stop there, you will have the tentative code, V08. Asymptomatic means
there are no symptoms. In the example, the physician dictated that there were
symptoms, so you must continue your search for the correct code. Just below
the term HIV, you see: with symptoms, symptomatic 042. Turn to code 042 in
the Tabular List to determine the highest level of specificity so that you know
you have accurately coded the symptomatic HIV infection. You will then assign
042 Human immunodeficiency virus [HIV] disease as the correct code.

0205502LB03A-24-13 24-9
Medical Coding and Billing Specialist

Before we move on to the other sections, let’s review what you’ve learned so far.
You’ll get a little hands-on practice here, too!

 Step 4 Practice Exercise 24-1

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Food poisoning
ICD-9-CM code: _______________________________

2. Infiltrative pulmonary tuberculosis, found by culture

ICD-9-CM code: _______________________________

3. Rabbit fever
ICD-9-CM code: _______________________________

4. Pertussis
ICD-9-CM code: _______________________________

5. Septicemia due to Bacteroides

ICD-9-CM code: _______________________________

6. Pneumocystis carinii pneumonia with AIDS

ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

24-10 0205502LB03A-24-13
 ICD-9-CM Coding—From Infections to Blood Diseases

Use the following information to complete the CMS-1500 that follows:

7. ICD-9-CM Coding/Billing Challenge

James Hahns, MD
800 Medical Court
Yourtown, CO 80000
(970) 555-2222

Patient Information
Name Rebecca Bloomquist Date of Birth June 25, 1997
Address 409 Yorkshire Sex F Marital Status single
City Yourtown State CO
ZIP 80001
Home Phone 970-555-5875

Employment Information
Name of Employer
Occupation
Student X Full-time Part-time

Insurance Information
Primary Insurance Secondary Insurance
Name Med Link HMO Name none
ID# 521 00 900602 ID#
Group# WBHMO Group#
Address PO Box 560 Address
City Yourtown City
State CO ZIP 80001 State ZIP
Primary Insured Name Dick Bloomquist Secondary Insured Name
Relation to Patient father Relation to Patient
DOB 03-10-1967 DOB
Employer Wilton Bookstore Employer
I authorize the release of any information including diagnosis and I authorize the release of any information including diagnosis
treatment. I authorize my insurance carrier to pay directly to the and treatment. I authorize my insurance carrier to pay directly
doctor any benefits otherwise payable to me. to the doctor any benefits otherwise payable to me.

Dick Bloomquist 
Signature of patient (or parent of minor child)
Signature of patient (or parent of minor child)

Physician signature: James Hahns MD

SSN: 900-00-9000
NPI: 0405674390
Participating Provider for: Medicaid and all private insurance

DateofService 5-8-20XX
Diagnosis Procedure Charge
99283 Emergency Dept. Level 3 $187.00

Today’s Charge $187.00

Cash/Check $0.00
Balance $187.00

0205502LB03A-24-13 24-11
Medical Coding and Billing Specialist

Rebecca Bloomquist
DOB: 6-25-1997
Date of service 5-8-20XX

SUBJECTIVE
The patient presents to the emergency department with fever, chills,
lethargy and loss of appetite for the past 2 days.

OBJECTIVE
Physical examination was significant for fever and decrease in body
temperature and blood pressure. Hands and feet are cold to the touch.
Urine culture, CBC and blood gasses are ordered. Patient is given IV
fluid and oxygen.

ASSESSMENT
Lab results indicate gram-negative septicemia with systemic
inflammatory response syndrome.

PLAN
Patient is admitted by her PCP for further treatment.

24-12 0205502LB03A-24-13
 ICD-9-CM Coding—From Infections to Blood Diseases

1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
M F
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
Self Spouse Child Other

CITY STATE 8. PATIENT STATUS CITY STATE

Single Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
Employed
Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State) b. EMPLOYER’S NAME OR SCHOOL NAME
M F YES NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED DATE SIGNED

14. DATE OF CURRENT ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
INJURY (Accident) OR GIVE FIRST DATE
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

17b. NPI FROM TO

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. . 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
FROM TO PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
YES NO $ $ $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 33. BILLING PROVIDER INFO & PH #
DEGREES OR CREDENTIALS (I certify that the statements on the 32. SERVICE FACILITY LOCATION INFORMATION
reverse apply to this bill and are made a part thereof.)

SIGNED DATE a. b. a. b.

0205502LB03A-24-13 24-13
Medical Coding and Billing Specialist

 Step 5 Review Practice Exercise 24-1

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 6 Infectious and Parasitic Diseases (001-139), Part 2

 Now that you’ve “gotten your feet wet” with some real coding practice on a number of
different diseases, let’s continue learning about the diseases contained in Chapter 1 of
your ICD-9-CM manual’s Tabular List.

Poliomyelitis and Other Non-Arthropod-Borne Viral

Diseases and Prion Diseases of Central Nervous
System (045-049)
This section focuses on viral diseases of the central nervous system that are not
caused by parasites or infective organisms. Symptoms of these diseases are fever,
sore throat, headache and vomiting, often with stiffness of the neck and back.

Code category 045 is another example of codes that require the fifth-digit
subclassification. Turn to code category 045 in your ICD-9-CM. Under code 045
Acute poliomyelitis, you see a note that indicates you must submit a five-digit
code for your code to be accurate for this code category. The fifth-digit indicates the
poliovirus type.

Now let’s code nonparalytic poliomyelitis. To

begin coding, you must determine the coding
pathway. The main term is Poliomyelitis, and
the subterm is nonparalytic. When you follow
that coding pathway, you will find the tentative
code 045.2  in Volume 2, the Index to
Diseases. Now turn to 045.2 in the Tabular List
to determine the highest level of specificity.
The description is acute nonparalytic
poliomyelitis, yet acute is not in the dictation.
So is 045.2 the correct code?

To begin coding, you must

determine the coding pathway.

24-14 0205502LB03A-24-13
 ICD-9-CM Coding—From Infections to Blood Diseases

First, think back to your coding pathway. Did you locate the main term and
subterm correctly? Yes. Next, look at the terms under 045.2 Acute nonparalytic
poliomyelitis and you will see Poliomyelitis (acute) listed. Do you remember
those nonessential modifiers you learned about previously? The words in
parentheses here are nonessential modifiers. They may or may not be in the
dictation you receive, and they do not affect the code you assign. This means
that code 045.2 is correct, but it is lacking the fifth-digit. Refer to the shaded
box at the beginning of the 045 code group, and you’ll find the fifth-digit
subclassification is 0 for poliovirus, unspecified type. You will assign 045.20
Acute nonparalytic poliomyelitis, poliovirus, unspecified type as the final
code for this condition.

Viral Diseases Generally Accompanied by Exanthem

(050-059)
Viral diseases accompanied by exanthem are diseases that cause skin rashes,
such as smallpox, cowpox, chickenpox, herpes zoster, herpes simplex, measles and
rubella. Here are a few quick facts about some of these diseases:
 Variola major is a form of smallpox known for its high mortality. This
disease exists only in laboratories.
 Cowpox is a disease one contracts by milking infected cows.
 Chickenpox is also known as varicella.
 Herpes zoster is an infection that tends to cease after a definite period of
time. It causes unilateral skin eruptions along affected nerves.
 Rubella is an acute but usually benign infection that causes fever, sore
throat and rash.

You’ll find that most coding in this section is straightforward. Fourth and fifth
digits are provided in the Tabular List. Be sure to review each tentative code
to verify inclusions, exclusions and additional notes that will assist you.

Arthropod-Borne Viral Diseases (060-066)

The “Arthropod-borne Viral Diseases (060-066)” section
focuses on diseases that parasites and infective agents cause.
These are diseases such as yellow fever, mosquito-borne viral
encephalitis, tick-borne viral encephalitis and West Nile
fever. West Nile fever is mosquito-borne and may cause
fatal inflammation of the brain, the lining of the brain or
the lining of the brain and spinal cord.

West Nile fever is

mosquito-borne.

0205502LB03A-24-13 24-15
Medical Coding and Billing Specialist

Now see how quickly you can determine the correct code or codes for this sample dictation.

SUBJECTIVE
A 54-year-old male has just returned from a trip to Asia and complains of
fever, headache, lethargy, conjunctivitis and lower back pain.

OBJECTIVE
Lab tests indicate serological detection of IgM and IgG antibodies.

ASSESSMENT
Sandfly fever.

PLAN
CDC (Center for Disease Control and Prevention) will be contacted
for treatment.

To accurately code this condition, begin with the main term Fever in the
Index to Diseases. Once you have located Fever, find sandfly, the subterm, for
the tentative code 066.0. Then turn to the Tabular List and find this code to
determine the highest level of specificity. You will assign as the correct code
066.0 Phlebotomus fever for the diagnosis of sandfly fever.

Other Diseases Due to Viruses and Chlamydiae (070-079)

The “Other Diseases Due to Viruses and Chlamydiae” section includes diseases such
as viral hepatitis, rabies, warts and mumps. Viral hepatitis has several categories.
Hepatitis A often is found in areas of poor hygiene and low socioeconomic
standards. This form of hepatitis is transmitted via the fecal-oral route. Hepatitis
B is transmitted through contaminated needles, syringes, instruments and blood
products. This form of hepatitis also is spread by intimate contact. Hepatitis C
is the most common form of post-transfusion hepatitis. Hepatitis E, also called
non-A and non-B, usually is transmitted through contaminated water.

You will find the fifth-digit subclassification for codes 070.2 and 070.3 under the
070 Viral hepatitis heading. Turn to 070 in the Tabular List now, and look
at the shaded fifth-digit subclassification box.

Let’s practice by looking up the diagnosis code for viral hepatitis B Hepatitis B may be
with a hepatic coma. You will find the main term Hepatitis in the transmitted through
Index to Diseases. Once you have located the main term, find the contaminated needles,
subterms viral and type B. But your search is not complete yet! syringes, instruments and
Once you have located the subterms with and hepatic coma, you are blood products.
provided the tentative code of 070.20. You then turn to the Tabular
List to determine the highest level of specificity. You will assign
code 070.20 Viral hepatitis B with hepatic coma, acute or
unspecified, without mention of hepatitis delta.

24-16 0205502LB03A-24-13
 ICD-9-CM Coding—From Infections to Blood Diseases

Rickettsioses and Other Arthropod-Borne

Diseases (080-088)
Rickettsia is a type of parasitic organism. These
organisms multiply by invading the cells of another life
form, usually arthropods (lice, fleas, ticks and mites).
These arthropods can then transmit rickettsiae to
rodents, dogs and even humans through saliva from a
bite or feces being deposited on a small break in the skin.
The codes in this section are fairly simple; but do note
that when you look in this section of the Tabular List,
you will find instructions to use codes 060.0 through
066.9 for arthropod-borne viral diseases instead of
the codes you find in this section. If you have a hard
time understanding anything in this section, call your
instructor. Remember, we want you to succeed, and your The use of the ICD-9-CM manual
instructor will be available to answer your questions! gets easier with practice.

Use of the ICD-9-CM manual gets easier with practice. The more you use the
volumes and learn to recognize additional information, the easier diagnostic coding
becomes! Now let’s take a few minutes to review the sections you just studied.

 Step 7 Practice Exercise 24-2

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Viral encephalitis
ICD-9-CM code: _______________________________

2. Varioloid
ICD-9-CM code: _______________________________

3. Measles with otitis media

ICD-9-CM code: _______________________________

4. German measles
ICD-9-CM code: _______________________________

5. West Nile fever

ICD-9-CM code: _______________________________

6. Rabies
ICD-9-CM code: _______________________________

0205502LB03A-24-13 24-17
Medical Coding and Billing Specialist

7. Hand, foot and mouth disease

ICD-9-CM code: _______________________________

8. Lyme disease
ICD-9-CM code: _______________________________

9. ICD-9-CM Coding Challenge

SUBJECTIVE
Two weeks ago this 7-year-old female presented with a low-grade fever, headache,
and stuffy nose lasting three days. A couple of days after symptoms subsided,
patient noticed a bright red rash on her face. Patient now presents with similar
rash on trunk, arms, and legs, times one week.

OBJECTIVE
Physical examination reveals net-like rash on face, trunk, arms and legs.

ASSESSMENT
Patient has fifth disease.

PLAN
Plenty of bed rest. Drink lots of clear fluids and take acetaminophen as needed to
reduce fever. Call office if rash does not begin to clear within 10 days.
ICD-9-CM code: _______________________________

 Step 8 Review Practice Exercise 24-2

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 9 Infectious and Parasitic Diseases (001-139), Part 3

 This is the final section in Chapter 1 of the ICD-9-CM manual’s Volume 1, the
Tabular List. So read on, and let’s finish the diseases in this chapter!

Syphilis and Other Venereal Diseases (090-099)

Syphilis is a chronic infectious disease usually transmitted through sexual contact.
Untreated syphilis progresses through three clinical stages: primary, secondary
and tertiary. In the primary stage of syphilis, a painless lesion appears. The
secondary stage produces widespread lesions. The tertiary stage produces
destructive lesions that involve many organs and tissues.

24-18 0205502LB03A-24-13
 ICD-9-CM Coding—From Infections to Blood Diseases

If you turn to “Syphilis and Other Venereal Diseases (090-099)” in the Tabular List,
you’ll find that this section EXCLUDES nonvenereal endemic syphilis, stating that
you should use code 104.0 instead; it also EXCLUDES urogenital trichomoniasis,
stating you should use code 131.0 instead.

Turn again to your ICD-9-CM manual for some coding practice in this section, using
the following dictation sample:

SUBJECTIVE
A 19-year-old female is seen in the emergency department complaining
of a sore on her buttocks. Sore was noted about 13 days ago.

OBJECTIVE
Anus was examined. Blood tested positive for syphilis.

ASSESSMENT
Primary anal syphilis.

PLAN
Patient discharged with prescription for antibiotics.

As the medical coding and billing specialist, you begin with the main term Syphilis
in the Index to Diseases. The subterms anus and primary will direct you to 091.1
as the tentative code. To determine the highest level of specificity, locate that code
in the Tabular List. Based on what you find there, you can then assign code 091.1
Primary anal syphilis as the accurate code.

Other Spirochetal Diseases (100-104)

A spirochete is a spiral-shaped bacterium that causes diseases such as leptospirosis,
yaws and pinta. Leptospirosis is a rare disease where the spirochete is harbored
by rodents and excreted in their urine. After about one to three weeks, there is an
acute illness with fever, chills, an intense throbbing headache, severe muscle aches,
eye inflammation and a skin rash. The kidneys are severely affected, and there is
jaundice due to liver damage. Yaws is an infection that mainly affects the skin and
bones. It is found throughout the poorer subtropical and tropical areas of the world.
It is almost always acquired by children. After about three or four weeks following
infection, an itchy, raspberry-like growth appears. Scratching spreads the infection.
Pinta occurs in some remote villages in tropical America. It is unknown how the
disease is spread. Small spots surrounding a large spot appear on the face, neck,
buttocks, hands or feet. About one to twelve months later, red skin patches appear.
They eventually turn blue, then brown and finally white.

Although the codes in this section are not used much because these diseases are
rarely seen, be sure to call your instructor if you have any questions as you read
through the details about them in your coding manual.

0205502LB03A-24-13 24-19
Medical Coding and Billing Specialist

Mycoses (110-118)
Mycoses are diseases such as dermatophytosis, candidiasis, coccidioidomycosis and
others that are caused by a fungus. Dermatophytosis is a common fungal infection
of the skin, hair and nails. Candidiasis is a fungal infection usually found in the
mucous membranes or on moist skin. Coccidioidomycosis is caused by inhalation
of dust particles that contain arthrospores. This disease is a self-limiting respiratory
infection, and the primary form is known as San Joaquin fever, desert fever or
valley fever.

Many do not discover they suffer from mycoses until diseases such as those just
mentioned are activated because of the fungus.

The Tabular List instructs you to use additional codes to identify the manifestations
of the diseases in this section. You’ll recall that manifestations are signs of a disease,
or the outward expressions of an underlying condition.

Let’s work through an example. As the medical coding and billing specialist for a
pediatrician, you have the following situation to code:

An office visit takes place for an established patient with oral

thrush. A detailed history and problem focused examination are
documented. The pediatrician prescribes antifungal agent for oral
thrush and instructs the patient to return if the problem persists.

Open your ICD-9-CM manual to the main term Thrush in the Index to Diseases.
The subterm oral has no effect on the tentative code 112.0. Determine the highest
level of specificity for this code in the Tabular List. Note that the description for code
112.0 Candidiasis, Of mouth is appropriate because thrush (oral) is included in
that description. Therefore, you assign code 112.0 as the correct code.

How are you doing by this point? Are you beginning to automatically move through
the steps of identifying the main term and subterm? Are you then using these terms
to locate the condition in the Index to Diseases, and then going to the Tabular List
to determine the degree of specificity and confirm the accuracy of the tentative code
you’ve selected? If the process doesn’t feel quite automatic yet, be patient—it’s only a
matter of time until you’ll be coding more easily, without having to think about each
step you take.

Helminthiases (120-129)
Helminthiases are infections associated with worms. Diseases of this section include
tapeworms, hookworms and other intestinal parasites. For example, echinococcosis
is an infection caused by larval forms of tapeworms. Direct contact with infected feces
transmits this disease. Most people with echinococcosis are asymptomatic until cysts
are formed, which then cause pain, occlusion or organ dysfunction.

24-20 0205502LB03A-24-13
 ICD-9-CM Coding—From Infections to Blood Diseases

Other Infectious and Parasitic Diseases (130-136)

Diseases of this section are toxoplasmosis, scabies and sarcoidosis. As the title
suggests, these diseases are either contagious or the result of parasites. Some examples
of parasites that can cause diseases in these code groups are lice, mites and fleas.

For our coding example in this section, let’s code trichomonal urethritis. To begin
your search for the accurate code, once again start with the Index to Diseases. To
find the main term, remember to ask yourself, “What is the problem?” The problem
is urethritis, so locate Urethritis in the alphabetical index. Next, ask yourself, “What
type of urethritis does the physician say it is?” If you answered trichomonal, you’re on
the right track! Under Urethritis in the index, find trichomonal. The Index to Diseases
indicates the tentative code is 131.02. Determine the highest level of specificity of this
code in the Tabular List. Based on the information there, you can confidently assign
131.02 Trichomonal urethritis as the correct code for this condition.

Late Effects of Infectious and Parasitic Diseases (137-139)

Remember that using the term late effects indicates that an infection no longer
is present. Do you remember learning about late effects in a previous lesson? If
a residual condition was documented with the late effect, you would code that
condition first, and then the late effect. Turn to code groups 137, 138 and 139 in
your manual, and be sure to read the notes associated with each group before you
complete the Practice Exercise for this section.

 Step 10 Practice Exercise 24-3

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Early cardiovascular syphilis

ICD-9-CM code: _______________________________

2. Acute gonococcal cystitis

ICD-9-CM code: _______________________________

3. Fungal infection of the foot

ICD-9-CM code: _______________________________

4. Desert fever
ICD-9-CM code: _______________________________

5. Hookworm disease
ICD-9-CM code: _______________________________

6. Norwegian scabies
ICD-9-CM code: _______________________________

0205502LB03A-24-13 24-21
Medical Coding and Billing Specialist

Use the following information to complete the CMS-1500 that follows:

7. ICD-9 Coding/Billing Challenge

James Hahns, MD
800 Medical Court
Yourtown, CO 80000
(970) 555-2222

Patient Information
Name Benjamin Fox Date of Birth 12/2/70
Address 1227 Comet Drive Apt 6B Sex male Marital Status single
City Springtown State CO
ZIP 80002
Home Phone 970-555-1001

Employment Information
Name of Employer Philco Gas
Occupation Driver
If Minor, Name of School

Insurance Information
Primary Insurance Secondary Insurance
Name Mountain States Name
ID# 520 00 7777 ID#
Group# 120 Group#
Address 1801 SW Vine St Address
City Denver City
State CO ZIP 80217 State ZIP
Primary Insured Name Benjamin Fox Secondary Insured Name
Relation to Patient Self Relation to Patient
Employer Philco Gas Employer
I authorize the release of any information including diagnosis and I authorize the release of any information including diagnosis
treatment. I authorize my insurance carrier to pay directly to the and treatment. I authorize my insurance carrier to pay directly
doctor any benefits otherwise payable to me. to the doctor any benefits otherwise payable to me.

Benjamin Fox
Signature of patient (or parent of minor child)
Signature of patient (or parent of minor child)

Physician signature: James Hahns MD

SSN: 900-00-9000
NPI: 0405674390
Participating Provider for: Medicaid and all private insurance

DateofService 6/14/XX
Diagnosis Procedure Charge
99213 Established patient Level 3 $63.00

Today’s Charge $63.00

Cash/Check $0.00
Balance $63.00

24-22 0205502LB03A-24-13
 ICD-9-CM Coding—From Infections to Blood Diseases

Name: Benjamin Fox

DOB: December 2, 1970
Date of Service: June 14, 20XX

CHIEF COMPLAINT
The patient comes for a routine follow-up appointment.

HISTORY OF PRESENT ILLNESS

This is a middle-aged African American male who comes today for routine follow-up.
He has no acute complaints. No neurological deficits or other specific problems. The
patient denies any symptoms associated with opportunistic infection.

PAST MEDICAL HISTORY

Immunizations: Up to date.
Current medications: (1) He is on Trizivir 1 tab p.o. b.i.d. (2) Ibuprofen over the
counter p.r.n.
Medication compliance: The patient is 100% compliant with his meds. He reports he
does not miss any doses. Drug intolerance: There is no known drug intolerance in
the past.
Illnesses: (1) Significant for HIV. (2) Chronic hepatitis. (3) PPD status was negative
in the past. PPD will be placed again today. Treatment adherence counseling was
performed by both nursing staff and myself. Again, the patient is 100% compliant
with his meds. Last dental exam was in 11/07, where he had 2 teeth extracted.
ALLERGIES: HE HAS NO KNOWN DRUG ALLERGIES.
Nutritional status: The patient eats regular diet and eats 3 meals a day.
Sexual history: He has had no recent STDs, and he is not currently sexually active.
Mental health and substance abuse: No history of substance abuse.

REVIEW OF SYSTEMS: Noncontributory except as mentioned in the HPI.

PHYSICAL EXAMINATION
GENERAL: This is a thinly built male, not in acute distress.
VITAL SIGNS: Blood pressure 132/89 and pulse of 82.
HEAD AND NECK: Reveals bilaterally reactive pupils. Supple neck. No thrush.
No adenopathy.
HEART: Heart sounds S1 and S2 regular. No murmur.
LUNGS: Clear bilaterally to auscultation.
ABDOMEN: Soft and nontender with good bowel sounds.
NEUROLOGIC: He is alert and oriented x 3 with no focal neurological deficit.
EXTREMITIES: Peripheral pulses are felt bilaterally. He has no pitting pedal
edema, clubbing or cyanosis.
GENITALIA: Examination of external genitalia is unremarkable. There are no
lesions.

DATABASE
Most recent labs show hemoglobin and hematocrit of 16 and 46. Creatinine of 0.6.
LFTs within normal limits. Viral load of less than 48 and CD4 count of 918.

CONTINUED

0205502LB03A-24-13 24-23
Medical Coding and Billing Specialist

ASSESSMENT
1. Human immunodeficiency virus, stable on Trizivir.
2. Chronic hepatitis C, stable.

PLAN
Continue his current meds. I have discussed with him in the past about possibility
of having to change off of his Trizivir in the future, if he develops resistance, since
triple NRTI therapy is not the preferred, but he is not amenable to that at this time.
He has excellent viremic control and good CD4 count. We will readdress this with
him in the future if his status changes. The patient is to have PPD placed today.
He has received his annual influenza vaccination for this season. He will be seen
again by the dental clinic for routine evaluation and have labs today including CD4,
viral load, RPR, and urinalysis. He will return to our clinic in 6 months. The patient
does not want to be seen more often since he has a job that he reports to and cannot
miss more days off work. Again this is acceptable since he has excellent viremic
control. The patient has been educated regarding his meds and plan. His prognosis
is excellent, and he will follow up with us in 6 months.

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 ICD-9-CM Coding—From Infections to Blood Diseases

1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
M F
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
Self Spouse Child Other

CITY STATE 8. PATIENT STATUS CITY STATE

Single Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
Employed
Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State) b. EMPLOYER’S NAME OR SCHOOL NAME
M F YES NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED DATE SIGNED

14. DATE OF CURRENT ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
INJURY (Accident) OR GIVE FIRST DATE
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

17b. NPI FROM TO

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. . 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
FROM TO PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
YES NO $ $ $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 33. BILLING PROVIDER INFO & PH #
DEGREES OR CREDENTIALS (I certify that the statements on the 32. SERVICE FACILITY LOCATION INFORMATION
reverse apply to this bill and are made a part thereof.)

SIGNED DATE a. b. a. b.

0205502LB03A-24-13 24-25
Medical Coding and Billing Specialist

 Step 11 Review Practice Exercise 24-3

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 12 Neoplasms (140-239)

 All neoplasms are classified in Chapter 2 of the ICD-9-CM manual’s Tabular List.
The following sections are included there:

140-195 Malignant neoplasms, stated or presumed to be primary, of

specified sites, except of lymphatic and hematopoietic tissue
196-198 Malignant neoplasms, stated or presumed to be secondary, of
specified sites
199 Malignant neoplasms, without specification of site
200-208 Malignant neoplasms, stated or presumed to be primary, of
lymphatic and hematopoietic tissue
209 Neuroendocrine tumors
210-229 Benign neoplasms
230-234 Carcinoma in situ
235-238 Neoplasms of uncertain behavior
239 Neoplasms of unspecified nature

In the ICD-9-CM manual, neoplasms are classified according to the following:

1. Behavior of the neoplasm, such as malignant or benign

2. Anatomical site involved, such as lung, brain or stomach
3. Morphology type, such as leukemia, melanoma or adenocarcinoma

Let’s look at each in more detail.

Classification by Behavior
The term neoplasm refers to any new and abnormal growth. The following definitions
describe the behavior of specific neoplasms:

Malignant—Malignant neoplasms are collectively referred to as cancers.

Primary—This term refers to the site at which a neoplasm originated.

Secondary—This term refers to the site or sites to which the neoplasm has spread
from the primary site.

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 ICD-9-CM Coding—From Infections to Blood Diseases

In Situ—This term describes the situation when the tumor cells are undergoing
malignant changes but still are confined to the point of origin without invasion of the
surrounding normal tissue.

Benign—This term refers to noncancerous growths. In benign neoplasms, growth

does not invade adjacent structures or spread to distant sites, but it might displace
or exert pressure on adjacent structures.

Uncertain Behavior—This term refers to tumors that the pathologist cannot

classify as benign or malignant because some features of each type are present.

Unspecified Nature—This term refers to tumors in which neither the behavior nor
the histological type are specified in the diagnosis.

The Neoplasm table is in Volume 2, Index to Diseases, under the main term Neoplasm.
This table includes seven columns, with the first column listing the anatomical sites
in alphabetic order. The remaining six columns identify the behavior of the neoplasm.
The first three columns include codes of Malignant neoplasms and are further
classified as Primary, Secondary and Ca in Situ, which stands for Carcinoma in Situ.
The fourth column identifies codes for benign neoplasms. The last two columns include
codes for neoplasms of Uncertain Behavior or of Unspecified type.

Classification by Primary Site

The primary site is defined as the tumor’s point of origin. In some cases, the physician
cannot identify the primary site; in these cases, the code 199.1 is provided for
unknown site or unspecified. You can assign this code whether the site is primary or
secondary in nature.

When adjunct chemotherapy or radiotherapy follows surgical removal of a primary-site

malignancy, you assign the malignancy code as long as chemotherapy or radiotherapy is
actively administered. If a primary malignant neoplasm that previously was removed by
surgery or eradicated by radiotherapy or chemotherapy reoccurs, you assign the primary
malignant code for that site unless the Index to Diseases directs you otherwise.

The terms metastasis and direct extension both are classified as secondary malignant
neoplasms in the ICD-9-CM manual. Cancer described as metastatic to a specific site is
interpreted as a secondary neoplasm of that site. We’ll discuss this in more detail shortly.

Classification by Morphology Type

The morphology type of a neoplasm is determined based on looking at abnormal cells
from different parts of the body in a microscope and naming and classifying those cells
according to their original tissue type. Such classification is possible because most
benign tumors and many malignant ones retain some microscopic features of their
original tissue. Tumors are named according to the cell type they resemble most.

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Medical Coding and Billing Specialist

The codes in this chapter of the ICD-9-CM book do not include personal or family
history of malignant neoplasms. Personal history of a malignant neoplasm means
that the past medical condition no longer exists, and the patient is not receiving
any treatment. Family history codes are used when a patient has a family
member who had a particular disease, which causes the patient to be at higher
risk for contracting the disease. These instances are coded from the V10 and V16
categories instead.

Malignant Neoplasms (140-208)

Malignant neoplasms often become progressively worse and can eventually result
in death. These neoplasms are cancers. Malignant neoplasms are grouped into the
behavioral categories of primary, secondary and carcinoma in situ. You’ll remember
that primary refers to the site at which the neoplasm originated. Secondary refers to
the site to which the primary site has spread. Carcinoma in situ refers to tumor cells
that are confined to the site of origin and have not invaded the surrounding normal
tissue. You also may see the terms metastasis and direct extension when you are
classifying a secondary malignant neoplasm.

Metastasis is the transfer of a disease from one organ or part to another organ or
part not directly connected with it. Only malignant tumor cells have the capacity to
metastasize. Malignant cells can spread through the body very quickly. The three
main pathways they use are the lymph nodes, the blood and the surface of body
cavities. If a person has lung cancer that has metastasized to the brain, the primary
malignant neoplasm is the lung, and the secondary malignant neoplasm is the brain.
It is possible to have a secondary neoplasm with the primary site unknown.

Let’s code for a patient being treated for a secondary malignant neoplasm of the lymph
gland located in the leg, with the primary site unknown. First, code the secondary
neoplasm as the treatment is directed toward that site. Use the Neoplasm table, found
in the Index to Diseases, under the main term Neoplasm. Locate lymph, gland, leg
and then move to the Malignant, Secondary column for the tentative code of 196.5.
Now, code the primary neoplasm. Locate the subterms unknown site or unspecified
in the Neoplasm table (you are no longer under the subterm lymph) then move to the
Malignant, Primary column. The tentative code is 199.1. Turn to the Tabular List to
determine the highest level of specificity for both codes. You will then assign 196.5
Secondary and unspecified malignancy neoplasm of lymph nodes, Lymph
nodes of inguinal region and lower limb, as well as coexisting condition 199.1
Malignant neoplasm without specification of site, Other.

The morphological names for malignant neoplasms come from the names of
the cell type, with the suffix -sarcoma added. For example, fibrosarcoma is
a malignant neoplasm derived from fibrous tissue. Chondrosarcoma is a
malignant neoplasm of cartilage cells. Liposarcoma is a malignant neoplasm of
adults that occurs in the tissues and the thigh.

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 ICD-9-CM Coding—From Infections to Blood Diseases

Of course, you don’t need to memorize these meanings because the Index to Diseases
assists you when you’re using these morphological classifications to code. For
example, open your ICD-9-CM manual to the index and locate Fibrosarcoma. The
manual directs you to see also Neoplasm, connective tissue, malignant. You will then
use the Neoplasm Table to locate connective tissue NEC. Unless otherwise stated,
the malignant neoplasm is primary. Move to the Malignant, Primary column for the
tentative code 171.9, and then check this code in the Tabular List to determine the
highest level of specificity.

Let’s make sure you have the general idea of everything you’ve just read. One
form of malignant tumor is known as Kaposi’s sarcoma, which is a dermal tumor
made up of blood vessels and vascular tissue cells. These tumors are red due to
the leakage of blood at the surface of the skin. They multiply rapidly and can
cover the entire surface of the body. Kaposi’s sarcoma is an eponym, named for a
person. Remember learning about eponyms in previous lessons? To locate the code
for Kaposi’s sarcoma in the Index to Diseases, find the main term Kaposi’s. The
subterm sarcoma indicates that the code 176.9 would be the tentative code for this
condition. As always, determine the highest level of specificity in the Tabular List.

Neuroendocrine Tumors (209)

Neuroendocrine tumors affect hormone-producing cells, present throughout
the nervous and endocrine systems. Most neuroendocrine tumors are not able to
be described as a specific type of cancer, therefore are termed carcinoid tumors.
Carcinoid tumors are a slow-growing type of cancer that can arise in several places
throughout your body, usually in the gastrointestinal tract (appendix, stomach, small
intestine, colon, rectum) and in the lungs. The American Cancer Society defines
carcinoid as the following:

“Like most cells of the body, gastrointestinal system neuroendocrine cells sometimes
undergo certain changes that cause them to grow too much and form tumors. The
tumors that develop from neuroendocrine cells are known as neuroendocrine tumors
(or neuroendocrine cancers). There are many varieties of neuroendocrine tumors, but
the most common are the carcinoid tumors or carcinoids.”

Carcinoid tumors act like the cells they come from. They often release certain
hormone-like substances into the bloodstream. In about 10 percent of people, the
carcinoid tumors spread and grow very large and release high amounts of those
hormones. These cause symptoms such as facial flushing (redness and warm
feeling), wheezing, diarrhea and a fast heartbeat. These symptoms are grouped
together and called the carcinoid syndrome. Most cancers cause symptoms only in
the organs they start in or spread to. But carcinoid tumors can release substances
into the blood that cause symptoms throughout the body.

Turn in your Tabular List to code 209.3. This code specifies the neuroendocrine
tumor is poorly differentiated. Poorly differentiated tumors are rare, fast
growing and, therefore, highly malignant.

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Medical Coding and Billing Specialist

Benign Neoplasms (210-229)

Benign neoplasms are noncancerous growths. These growths do not invade adjacent
structures or spread to distant sites, but they might displace or exert pressure on
adjacent structures. Benign tumors always remain localized and never metastasize.

To understand the morphological classification of benign neoplasms, refer to

your medical terminology lessons. The suffix -oma is a word part that means
“tumor” or “neoplasm.” For example, adenoma is a benign neoplasm of
epithelial cells. Again, you do not need to memorize such terms because the
Index to Diseases is available to assist you. When you look up the main term
Adenoma in the index, you are directed to see also Neoplasm, by site, benign.
This cross-reference instructs you to turn to the Neoplasm Table and locate the
site and then find the correct code in the Benign column.

Let’s say you are given the diagnosis of papilloma of the larynx. First, locate the
main term Papilloma in the Index to Diseases. Note that you are directed to see
also Neoplasm, by site, benign. Again, turn to the Neoplasm Table and locate larynx
NEC. Once you find the term, move to the Benign column to determine that code
212.1 is the tentative code for papilloma of the larynx. Check the code 212.1 in
the Tabular List to determine the highest level of specificity and assign that code.

Now that we have described benign and malignant tumors, compare the difference
in the tumor types in the following illustrations.

intact skin surface invasive growth u lceration of skin l ymphatic invasion

expansile growth capsule homogeneous inhomogeneous necrosis hemorrhage vessel invasion

cut surface cut surface
A Benign tumor B Malignant tumor

Carcinoma in Situ (230-234)

In situ describes tumor cells that are undergoing malignant changes but are still
confined to the site of origin without invasion of surrounding normal tissue. The
physician will specifically state the behavior of the neoplasm as being in situ if
you are to code this type.

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 ICD-9-CM Coding—From Infections to Blood Diseases

Neoplasms of Uncertain Behavior (235-238)

Now, let’s turn to code 235 in the Tabular List. There, you’ll see a note for code
categories 235 through 238. The note under the title of this section tells you
that the codes classify by site certain histomorphologically well-defined
neoplasms whose subsequent behavior cannot be predicted from the present
appearance. You should be aware that this note means you must assign the code
of uncertain behavior for tumors that the pathologist cannot classify as benign
or malignant because some features of each type are present. Review the code
categories in this section, and notice the various INCLUDES and EXCLUDES ,
as well as those codes that require fourth- and fifth-digit classifications.

Take a look at the following operative report and see whether you can identify the
correct code or codes for the indicated diagnosis.

PREOPERATIVE DIAGNOSIS
Mass on right breast.
A 40-year-old female presents with mass on the right breast. Review of recent
mammogram indicates the mass is in the upper-outer quadrant.

PROCEDURE PERFORMED
BREAST BIOPSY.
A large-gauge needle is inserted through the skin of the breast into the mass.
The needle is removed with the core of breast tissue. Pressure is applied for
bleeding. The sample was sent to the pathologist, who was unable to classify
the mass as benign or malignant.

POSTOPERATIVE DIAGNOSIS
Breast neoplasm of uncertain behavior.

To code this operative report, begin at the Neoplasm Table in the Index to Diseases.
Locate breast in this table, and then move to the Uncertain Behavior column, where
you’ll find the tentative code of 238.3. Once you have determined the highest level
of specificity in the Tabular List, you can comfortably assign 238.3 Neoplasm of
uncertain behavior of other and unspecified sites and tissues, Breast for
this report.

Neoplasms of Unspecified Nature (239)

Unspecified nature refers to tumors in which neither the behavior nor the
histological types are specified in the diagnosis. Turn to the Tabular List to read the
note found for code 239. Notice that the note refers to neoplasms of unspecified
morphology and behavior. To help you code conditions in this group, keep
in mind that the words histology and histological mean the same thing as do
morphology and morphological.

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Medical Coding and Billing Specialist

Exceptions and Clarifications

You should be aware of some important exceptions to the rules
we’ve discussed for codes included in Chapter 2 of the Tabular
List. For example, not all tumors that end in -oma are benign,
and not all malignant tumors are labeled as carcinomas
or sarcomas. An important example of this exception is
lymphoma, a malignant tumor of lymphoid cells. However,
there is no need to memorize this information because the
Index to Diseases will guide you when you are searching for Be aware of some
these main terms. important exceptions to
the rules we’ve discussed.

 Step 13 Practice Exercise 24-4

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Recurrent glioma of cerebrum

ICD-9-CM code: _______________________________

2. Metastatic carcinoma of the brain from the lung

ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

3. Hodgkin’s sarcoma
ICD-9-CM code: _______________________________

4. Benign neoplasm scalp

ICD-9-CM code: _______________________________

5. Fibromyoma of the uterus

ICD-9-CM code: _______________________________

6. ICD-9-CM Coding Challenge

PATHOLOGY REPORT
SPECIMEN: Biopsy, lesser curvature.
DATE COMPLETED: June 7, 20XX
GROSS DESCRIPTION: Multiple fragments pale tan tissue, measuring
1 x 0.6 x 0.3 cm in aggregate.
MICROSCOPIC/DIAGNOSIS: Gastric biopsy: Adenocarcinoma.
ICD-9-CM code: _______________________

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 Step 14 Review Practice Exercise 24-4

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 15 Endocrine, Nutritional and Metabolic

Diseases, and Immunity Disorders (240-279)
 Chapter 3 of the Tabular List focuses on diseases and
disorders of the endocrine system, nutritional deficiencies and
disorders and disturbances of the metabolic and immunity
systems. When these systems are off balance, the body is
affected. We will discuss items such as hyperplasia, diabetes,
Cushing’s syndrome and anemia.

First, let’s look at this chapter in the Tabular List to become

familiar with the inclusions, exclusions and additional notes
provided. Next to EXCLUDES under the chapter title, you see
that you should use codes 775.0 through 775.9 for endocrine and
metabolic disturbances specified to the fetus and newborn. There
also is a note stating that all neoplasms, whether functionally
active or not, are classified in Chapter 2. Codes in Chapter 3,
that is, codes 242.8, 246.0, 251 through 253, and 255 through Look at Chapter 3 in the
259 may be used to identify such functional activity associated Tabular List to become familiar
with any neoplasm, or by ectopic endocrine tissue. with the inclusions, exclusions
and additional notes provided.
Now, let’s talk about each of this chapter’s four sections.

Disorders of Thyroid Gland (240-246)

The thyroid gland is one of the endocrine glands, and it is normally situated
in the lower part of the front of the neck. The thyroid gland has two lobes, one
on either side of the trachea. This gland secretes and stores thyroid hormones.
Inadequate iodine levels often cause an enlarged thyroid gland.

In this section of the Tabular List, you will find EXCLUDES to assist you in selecting
the correct code. For example, in category 241 Nontoxic nodular goiter, you are
instructed to use category 226 instead for adenoma of thyroid and cystadenoma
of thyroid. Category 242 EXCLUDES neonatal thyrotoxicosis. Category 242 also
requires a fifth-digit subclassification. If you were to submit 242.0 for toxic diffuse
goiter, your code would be invalid until you applied the proper fifth digit.

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Medical Coding and Billing Specialist

Diseases of Other Endocrine Glands (249-259)

This section includes secondary diabetes mellitus, primary diabetes mellitus,
disorders of the parathyroid and pituitary glands and other endocrine disorders.

Diabetes mellitus is a chronic syndrome of insufficient insulin production

that leads to the body’s inability to metabolize carbohydrates, protein and fat.
This disease is genetic, but its development also depends on the individual’s
environment, including diet, weight and exercise habits. Diabetes mellitus occurs
in two major forms: type 1 and type 2. It is important that coders do not take
the patient’s age or the fact that insulin is documented when determining the
final digit for diabetes. Documentation must specifically note “type 1” or “type
2” for consideration. If the type of diabetes is not documented, you should check
with the physician for clarification. If the type can still not be documented, you
will code to unspecified. Long-term complications of the disease involve the
kidneys, nerves, blood vessels and eyes. Diabetes also is identified as controlled
or uncontrolled. For a diagnosis to be coded as uncontrolled, the physician must
specifically document it as such. We will discuss how to use this information to
determine codes when we look through the Tabular List.

Secondary diabetes mellitus is defined as a diabetic condition not as a result

of genetics or environmental conditions. Sometimes, determining primary or
secondary diabetes may be a challenge; however, the major differentiating factor
of secondary diabetes is the presence of another underlying condition that is
determined to be the cause of the diabetes. For instance, a patient may develop
secondary diabetes when pancreatic tissue is destroyed by chronic pancreatitis.

You will find reporting and sequencing issues addressed in the Coding Guidelines
in the front of your ICD-9-CM.

Now, open your ICD-9-CM manual to the Tabular List to review the fifth-digit
subclassification of code 250 Diabetes mellitus. The fifth-digit 0 indicates type
2 or unspecified type, not stated as uncontrolled. Use 0 as the final digit
when the physician documents type 2 diabetes or does not state the type.

If it is documented that a type 2 diabetic patient uses insulin on a long-term basis,

code V58.67 Long-term (current) use of insulin will also be assigned. You will
not use code V58.67 if insulin is given temporarily to a type 2 diabetic patient to
bring their diabetes under control. Remember, you will learn more about using V
codes in a later lesson.

The fifth-digit 1 indicates type 1 [juvenile type], not stated as uncontrolled. Use 1
as the final digit when the physician documents type 1 diabetes.

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Controlled and Uncontrolled Diabetes

A patient with a diagnosis of controlled diabetes has acceptable
blood sugar levels in his blood. Uncontrolled diabetes
may be documented when according to the patient’s
current treatment regimen, the blood sugar levels are not
acceptable. You will use the fifth-digits 2 and 3 only when
uncontrolled is clearly documented. Documenting the blood
sugar level is not within an acceptable level or the insulin
requires adjusting is not “uncontrolled.” In other words, if
you do not see “uncontrolled” in the dictation, you will not
use 2 or 3 as the fifth digit. The fifth-digit would be 2 when A patient with a diagnosis
uncontrolled is documented with type 2 or when the type is of controlled diabetes has
not specified. You will use the fifth-digit 3 when uncontrolled acceptable blood sugar levels
and type 1 diabetes is documented. in his blood.

Let’s use your ICD-9-CM book to code the disease you’ve just learned so much about.
A type 2 diabetic patient with long-term insulin use is diagnosed with ketoacidosis.
Begin your search for the accurate code in the Index to Diseases. To determine the
main term, ask yourself “what is the problem?” The problem is the ketoacidosis.
Once you find Ketoacidosis in the index, locate the subterm diabetic, and you will
find the tentative code 250.1  . If you stop there, you will not have the correct code
because you haven’t attended to the fifth-digit subclassification box. Turn to code
250.1 in the Tabular List to determine the highest level of specificity. The description
of diabetes with ketoacidosis is correct. Now, refer to the top of this category
for the fifth digit. You will use the fifth-digit 0 to indicate type 2, not stated as
uncontrolled. Be sure to read the notes in the 250 category. You are directed to use
an additional code for associated long-term insulin use with V58.67. It is documented
that the patient uses insulin on a long term basis, so this code would apply. The final
codes for this situation are 250.10 Diabetes with ketoacidosis, type 2, not stated
as uncontrolled and V58.67 Long-term (current) use of insulin.

You know that conditions can cause diabetes, resulting in secondary diabetes;
however, diabetes can cause the manifestation of other diseases as well. Turn to
the Tabular List and locate codes 250.4 through 250.8. These subcategories are
for diabetes with manifestations, and below each category you are instructed to
use an additional code to identify the manifestation. You must assign both codes
to fully describe the condition, and the codes must be sequenced in the order
listed in the manual.

Diabetes is a challenging disease to code, so let’s try another example. This time,
let’s code a patient with manifestations resulting from the diabetes. You are the
medical coding and billing specialist for an ophthalmologist, and you must code the
following dictation:

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Medical Coding and Billing Specialist

SUBJECTIVE
A 64-year-old male with a history of type 1 diabetes complains of cloudy,
obstructed vision.
OBJECTIVE
Exam of the eye reveals snowflake shaped opacity.
ASSESSMENT
The physician determines the patient has diabetic cataracts and suggests
outpatient surgery.
PLAN
The extracapsular cataract is removed with insertion of an intraocular lens.
The patient is instructed to return for follow-up treatment.

The patient complains of cloudy, obstructed vision, but you don’t code symptoms
when a final diagnosis is provided. The physician’s assessment revealed diabetic
cataracts to be the problem. So, is the main term the diabetes or the cataracts?
To find out, let’s use Cataract as the main term and turn to the Index of Diseases.
Once you have located the main term, you’ll look for the subterm diabetic. So the
tentative codes are 250.5  [366.41]. (Remember that the slanted brackets
indicate the manifestation of the underlying condition.) Now, what if diabetes is
the main term? Locate Diabetes as the main term in the index, with cataract as
the subterm. What do you see? The tentative codes listed are 250.5  [366.41].
So you see that there is more than one way to the correct code.

Now let’s go back to the manual and search for the final codes for this example. You
know from the information you just read about coding manifestations that you must
use both codes and sequence them in the order listed. Turn to code 250.5 in the
Tabular List to determine the highest level of specificity. It is documented that the
patient has type 1 diabetes, and the disease is not stated as uncontrolled. Therefore,
you would assign codes 250.51 Diabetes with ophthalmic manifestations, type
1 [juvenile type], not stated as uncontrolled and 366.41 Diabetic cataract for
this scenario. You will use code 366.41 without recording the brackets.

Now that you have a basic understanding of diabetes, let’s move on by looking at
the Tabular List for other notes in this section. The section lists many INCLUDES
and EXCLUDES . We will discuss some of those here, but be sure to read this area
closely on your own, as well.

Many codes in category 251 EXCLUDES conditions related to diabetes mellitus and
suggest other codes. For example, subcategories 251.0 and 251.1 indicate the need
for an E code to identify the cause if the condition is drug induced.

Cushing’s syndrome, another disease included in this section, is a syndrome that

causes fatty tissue of the face, neck and body. Note in the Tabular List that, for
code 255.0 Cushing’s syndrome, you are instructed to use an additional E code to
identify the cause if the condition is drug-induced. We will discuss E codes and how
they are used later on in this course.

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 ICD-9-CM Coding—From Infections to Blood Diseases

Nutritional Deficiencies (260-269)

This section covers diseases or conditions that are caused
by a lack of protein and vitamins and other nutritional
deficiencies. Under the heading “Nutritional Deficiencies
(260-269)” in the Tabular List, note that you are to
use codes 280.0 through 281.9 for deficiency anemias.
Code 263.9 Unspecified protein-calorie malnutrition
EXCLUDES code 269.9, which would be more appropriate
for an unspecified nutritional deficiency. And codes
266.1 Vitamin B6 deficiency and 266.2 Other B-complex
deficiencies direct you to other codes, as well. You also can
see that code 269.0 Deficiency of vitamin K EXCLUDES
deficiency of coagulation factor due to vitamin K
deficiency (286.7) and vitamin K deficiency of a
There are diseases and conditions
newborn (776.0).
that are caused by a lack of
Carefully read through the following report, thinking protein and vitamins, and other
about how you would determine the correct codes for nutritional deficiencies.
the diagnosis.

Operative Report
PREOPERATIVE DIAGNOSIS:
Suspect Osteomalacia.
A 52-year-old female presents with pain and tenderness in hip area as well as
overall weakness. Review of x-ray suggests signs of osteomalacia.
PROCEDURE PERFORMED
BONE BIOPSY.
Local anesthesia applied to procedure site. A small incision is made in the
skin, and a biopsy needle is pushed and twisted into the bone. Once the
bone sample is obtained, the needle is removed. Pressure is applied to
biopsy site for several minutes. No excess bleeding is noted. Site is covered
with gauze patch and secured.
POSTOPERATIVE DIAGNOSIS
Biopsy sample confirms osteomalacia.

To locate the code for this condition, open your ICD-9-CM manual to the Index to
Diseases, and then turn to the main term Osteomalacia. The tentative code you find
is 268.2. Now turn to the Tabular List to determine the highest level of specificity.
Based on the information you find, you see that you have coded the condition
correctly—268.2 Vitamin D deficiency, Osteomalacia, unspecified.

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Medical Coding and Billing Specialist

Other Metabolic and Immunity Disorders (270-279)

Anything that is considered abnormal when one is dealing with metabolism and
immunity is found in this section. Some diseases included in this chapter are albinism,
gout and obesity. This section also contains many eponyms, which are listed as
inclusions under the Tabular List code description. You are directed to use additional
code(s) to identify any associated intellectual disabilities with codes in this section.

Albinism is a rare inherited disorder in which melanocytes are present but they do
not form melanin. People with albinism have pale skin and white hair. Their eyes are
pink because the retina lacks pigment. Individuals with this condition are at high
risk for sunburn and skin cancer, and they must avoid the sun as much as possible.
There is no treatment for this disorder. To code for albinism, turn to the main term
Albinism, albino in the Index to Diseases. You will see many nonessential modifiers.
Remember, these words may not be present in the narrative description of a disease,
and they do not affect the code assignment. The tentative code 270.2 is indicated
for the disorder of albinism. Be sure to determine the highest level of specificity in
the Tabular List before you assign the code. Based on the information you have, the
correct code is 270.2 Other disturbances of aromatic amino-acid metabolism.

Gout is a group of diseases, all of which are characterized by various combinations

of deposits of uric acid crystals in the joints, certain tissues and the kidneys. Many
people who have gout show a family disposition to it, and the disease affects men
almost exclusively. The Tabular List notes that this category (274) EXCLUDES
lead gout, and you are directed to use codes 984.0 through 984.9 instead. To code
asymptomatic gout—gout with no symptoms—you begin in the Index to Diseases
by locating the main term Gout, gouty. Once you’ve found Gout, gouty in the index,
you will stop there because you do not have additional information to choose
a subterm. The tentative code provided is 274.9. Turn to the Tabular List to
determine the highest level of specificity for 274.9. You will then assign that code,
274.9 Gout, unspecified.

 Step 16 Diseases of the Blood and Blood-Forming

Organs (280-289)
 Chapter 4 in your ICD-9-CM manual is the last one we’ll cover in this lesson. The
chapter includes diseases such as anemias, coagulation defects, purpura, diseases
of the white blood cells and other diseases of blood and blood-forming organs.
Note from the Tabular List that this chapter EXCLUDES anemia complicating
pregnancy or the puerperium, for which you would use code 648.2. Become familiar
with the INCLUDES EXCLUDES and additional notes this chapter has to offer to
assist you in accurate coding.

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 ICD-9-CM Coding—From Infections to Blood Diseases

Anemia is any condition in which the number of red blood cells is less than normal.
Common signs of anemia include shortness of breath, palpitations of the heart and
lethargy. As you review the anemia section, be sure to note the inclusions, exclusions
and additional notes.

Iron deficiency anemia is the most common form of anemia and

probably the easiest to address. Iron deficiency is more common in
women than in men.

Sickle-cell anemia is a genetic disease most prevalent in Africans

and African-Americans. Just because an individual has sickle cell
anemia does not mean he will experience symptoms. Symptoms
depend on the amount of abnormal hemoglobin in the blood. Persons
with high levels of abnormal hemoglobin (at least above 40 percent,
but usually more) experience what are known as sickling
crises. Such crises result in infarcts (inadequate supply of blood
Iron deficiency is
to the tissues), which damage the vital organs. The diagnosis of
more common in
sickle cell anemia is made on the basis of clinical findings, but the
women than men.
disease can be confirmed only with laboratory tests.

Aplastic anemia is a rare type of anemia. There is a reduction in the number

of red, white and platelet cells in the blood. The earliest form of all blood cells in
the bone marrow is called stem cells. Aplastic anemia is a result of the failure to
produce these stem cells. The two major forms of aplastic anemia are idiopathic
aplastic anemia and secondary aplastic anemia. Idiopathic aplastic anemia, the
more common type, is a form of bone marrow failure that has no apparent cause.
The only known treatment for this type of anemia is a bone-marrow transplant.
The other major form, secondary aplastic anemia, is caused by bone marrow
suppression as a result of drugs, radiation therapy or viral infections. Secondary
aplastic anemias usually can be reversed by removing whatever caused the bone
marrow suppression in the first place.

Are you ready for another practice scenario? Consider that you’re the medical coding
and billing specialist for a physician who has prepared the following dictation:

PRESENTING PROBLEM
Suspect Anemia.
Patient presents with fatigue, SOB upon exertion, nosebleeds, and bleeding
gums, times three months. CBC indicates low RBC, WBC and platelet count.
PROCEDURE
BONE-MARROW BIOPSY.
Hip area is cleansed and local anesthetic is injected into site. Biopsy needle
is inserted into the bone. After the core of the needle is removed, the needle
is pressed forward and rotated, forcing tiny samples of the bone into the
needle. The needle is removed and pressure placed on the biopsy site.
POSTOPERATIVE DIAGNOSIS
Biopsy confirms idiopathic aplastic anemia.

0205502LB03A-24-13 24-39
Medical Coding and Billing Specialist

How did you do? Let’s review the main steps to correctly code this diagnosis. The
main term is Anemia, and the subterms are idiopathic and aplastic. Looking in the
Index to Diseases, you’ll find Anemia with a tentative code of 285.9. Looking further,
you see the subterm aplastic with a code of 284.9. But aplastic also has subterms,
including idiopathic, which once again indicates a tentative code of 284.9. Now
you turn to the Tabular List to determine the level of specificity for code 284.9.
There you’ll see that you have selected the correct code, 284.9 Aplastic anemia,
unspecified, which includes a sublisting for aplastic (idiopathic) NOS.

Coagulation defect is a failure to form blood clots. When you look in the Tabular
List under code 286, you will see a number of eponyms listed in this category (for
example, Rosenthal’s disease, Owren’s disease, von Willebrand’s disease and others).

Purpura is a condition visible through the skin and characterized by reddish-brown

or purplish spots. It is caused by bleeding within underlying tissues. The Tabular
List indicates that code 287 Purpura and other hemorrhagic conditions
EXCLUDES hemorrhagic thrombocythemia and purpura fulminans. Allergic
purpura is any hemorrhagic condition caused by a presumed allergic reaction to
food, drugs or insect bites.

When you look in the Tabular List, you’ll notice that code 288 Diseases of white
blood cells does not include leukemia. You should use subcategories 204.0
through 208.9 to code that disease. Eponyms also are often used in this category
and are listed under the Tabular List code description.

Leukopenia is a disease in which the white blood cell count is below normal.
Anything from drugs and environmental chemicals to radiation therapy and certain
chronic diseases can cause leukopenia. To code this condition, locate the main term
Leukopenia in the Index to Diseases, where you will find tentative code 288.50. Turn
to the Tabular List to determine the highest level of specificity. You will see the code
and description 288.50 Leukocytopenia, unspecified.

Finally, Chapter 4 addresses other diseases of blood

and blood-forming organs. These other diseases
include chronic lymphadenitis and hypersplenism.
Turn to coding group 289 in the Tabular List to
familiarize yourself with this group of codes, and
be sure to call your instructor if you need any help
understanding what you have read.

Leukopenia is a disease in Now review Chapters 3 and 4 of the ICD-9-CM

which the white blood cell manual by taking the following Practice Exercise.
count is below normal.

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 ICD-9-CM Coding—From Infections to Blood Diseases

 Step 17 Practice Exercise 24-5

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Postsurgical hypothyroidism
ICD-9-CM code: _______________________________

2. Type 1 diabetes hypoglycemic coma, uncontrolled

ICD-9-CM code: _______________________________

3. Primary hyperparathyroidism
ICD-9-CM code: _______________________________

4. Polycystic ovaries
ICD-9-CM code: _______________________________

5. Gouty arthropathy
ICD-9-CM code: _______________________________

6. Sickle-cell disease with crisis

ICD-9-CM code: _______________________________

7. Big spleen syndrome

ICD-9-CM code: _______________________________

0205502LB03A-24-13 24-41
Medical Coding and Billing Specialist

Use the following information to complete the CMS-1500 that follows.

8. ICD-9-CM Coding/Billing Challenge

FRONT RANGE FAMILY CARE ______ Greg Stephen, MD NPI: 0267679942

1800 Circle Court __X___ Donald Milford, MD NPI: 0810998051
Yourtown, CO 80000 ______ Douglas Smart, MD NPI: 0144878804
(970) 555-3344 Group NPI: 0881099885
Patient Information
Name Bonnie Schmidt Date of Birth June 25, 1952
Address 1810 Bluegrass Drive Sex F Marital Status married
City Springtown State CO
ZIP 80002
Home Phone 970-555-9041

Employment Information
Name of Employer Kain Graphics
Occupation graphic designer
If Minor, Name of School

Insurance Information
Primary Insurance Secondary Insurance
Name Country Group Name CHAMPVA
ID# 560001113 ID# 635 00 7213
Group# 208 Group#
Address PO Box 324 Address 4500 Cherry Creek Drive South; Box 64
City Springtown City Denver
State CO ZIP 80002 State CO ZIP 80222
Primary Insured Name Bonnie Secondary Insured Name Richard Schmidt
Relation to Patient self Relation to Patient Spouse
DOB same as above DOB Sept 15, 1952
Employer Kain Graphics Employer USAF
I authorize the release of any information including diagnosis and I authorize the release of any information including diagnosis
treatment. I authorize my insurance carrier to pay directly to the and treatment. I authorize my insurance carrier to pay directly
doctor any benefits otherwise payable to me. to the doctor any benefits otherwise payable to me.

Bonnie Schmidt
Signature of patient (or parent of minor child) Signature of patient (or parent of minor child)

Physician signature: Donald Milford, MD

SSN: 300-03-0303
EIN 66-6000600
Participating Provider for: TRICARE, CHAMPVA, Country Group and Blue Cross

DateofService 10/17/XX
Diagnosis Procedure Charge
99213 Est. Patient Level 3 $63.00

Today’s Charge $63.00

Cash/Check $0.00
Balance $63.00

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 ICD-9-CM Coding—From Infections to Blood Diseases

Bonnie Schmidt
DOB 06 25 1952
Date of Service 10/17/XX

SUBJECTIVE
At a regular office visit, patient complains of constipation, nausea and
vomiting, with abdominal pain, excessive thirst and muscle weakness.
Patient is currently receiving treatment for thyroid cancer.

OBJECTIVE
An expanded problem focused examination is performed. The physician
orders labs and an EKG, which are taken at the office. Results from
the blood draw indicate an elevated calcium level and, on the EKG, a
shortened Q-T interval.

ASSESSMENT
The patient has acute hypercalcemia resulting from the thyroid cancer.

PLAN
Orders for immediate hydration (3 L/day) and diuretic administration.

0205502LB03A-24-13 24-43
Medical Coding and Billing Specialist

1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
M F
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
Self Spouse Child Other

CITY STATE 8. PATIENT STATUS CITY STATE

Single Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
Employed
Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State) b. EMPLOYER’S NAME OR SCHOOL NAME
M F YES NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED DATE SIGNED

14. DATE OF CURRENT ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
INJURY (Accident) OR GIVE FIRST DATE
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

17b. NPI FROM TO

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. . 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
FROM TO PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
YES NO $ $ $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 33. BILLING PROVIDER INFO & PH #
DEGREES OR CREDENTIALS (I certify that the statements on the 32. SERVICE FACILITY LOCATION INFORMATION
reverse apply to this bill and are made a part thereof.)

SIGNED DATE a. b. a. b.

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 ICD-9-CM Coding—From Infections to Blood Diseases

 Step 18 Review Practice Exercise 24-5

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 19 Lesson Summary

 What do you think of diagnosis coding so far? Are you beginning to
see how everything you learned in previous lessons, from medical
terminology to the ICD-9-CM Coding Guidelines, helps you as you code?

In this lesson we covered the first four chapters of Volume 1 (the

Tabular List) of your ICD-9-CM manual. You learned about the
sections of each chapter and about some of the diseases in each
section. We showed you important notes, inclusions and exclusions
from each section, which are designed to assist you as you code.
And throughout the lesson were plenty of examples and practice
exercises to give you more chances to code as you moved through
the material. If you found parts of this lesson challenging, that’s Call your instructor if
understandable! We covered a lot of information here, and this is you need help.
your first real attempt at diagnosis coding, so it’s only natural to
have questions. Reread through the parts you found confusing, and
be sure to contact your instructor with any remaining questions.
Remember: Our goal is the same as yours—for you to succeed!

The format of the next few lessons will be similar to this one. We’ll continue
to talk about the chapters in Volume 1 of your manual, the Tabular List, and
you’ll have more diagnosis coding practice. But before you move on, take the
quiz for this lesson to reinforce what you’ve learned.

 Step 20 Mail-in Quiz 24

 Follow the steps to complete the Quiz.

a. Be sure you’ve mastered the instructions and the Practice Exercises that this
Quiz covers.
b. Mark your answers on your Quiz. Remember to check your answers with the
lesson content.
c. When you’ve finished, transfer your answers to the Scanner Answer Sheet
included. Use only blue or black ink on your Scanner Answer Sheet.
d. Important! Please fill in all information requested on your Scanner Answer
Sheet or when submitting your Quiz online.
e. Submit your answers to the school via mail, fax or, to receive your grade
immediately, submit your answers online at www.uscareerinstitute.edu.

0205502LB03A-24-13 24-45
Medical Coding and Billing Specialist

Mail-in Quiz 24
 Choose the best answer from the choices provided.
Each item is worth 3.33 points.

1. The first four chapters of the Tabular List cover Infectious and Parasitic
Diseases; _____; and Diseases of the Blood and Blood-Forming Organs.
a. Neoplasms; Endocrine and Diabetes
b. Endocrine, Nutritional and Metabolic Diseases; Immunity Disorders
c. Neoplasms; Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders
d. Metabolic Diseases; Natural Disasters

2. Spirochete are spiral bacterium found in diseases such as _____.

a. leptospirosis
b. yaws
c. pinta
d. all of the above

3. The most common form of anemia is _____.

a. idiopathic aplastic anemia
b. sickle-cell anemia
c. secondary aplastic anemia
d. iron-deficiency anemia

4. Which is not a fifth-digit subclassification for category 045? _____

a. Poliovirus, unspecified type
b. Poliovirus type II
c. Poliovirus type III
d. Poliovirus type IV

5. In the Tabular List, category 038 states to use an additional code _____.
a. if you feel so inclined
b. for systemic inflammatory response syndrome (SIRS) (995.91-995.92)
c. to identify the organism
d. because 038 has been deleted

6. Once a patient’s condition has been coded 042, you _____ assign 795.71 or
V08 to that patient again.
a. always
b. sometimes
c. probably
d. cannot

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7. Which statement is not true about the term metastasis? _____

a. It’s used when classifying a primary malignant neoplasm.
b. It’s the transfer of a disease from one organ or part to another organ or part.
c. It’s used when classifying a secondary malignant neoplasm.
d. Only malignant tumor cells have the capacity to metastasize.

8. To code 250.02, the documentation must indicate _____.

a. Type 2
b. Type 2, uncontrolled
c. Type 1, uncontrolled
d. Type 1

9. Which statement is not true of people with albinism? _____

a. They have pale skin and white hair.
b. They can stay out in the sun as much as possible.
c. Their eyes are pink because the retina lacks pigment.
d. They are at high risk for sunburn and skin cancer.

10. After looking up Dermatofibroma in the Index to Diseases, you should _____.
a. assign M8832/0 as the final diagnosis
b. see Neoplasm, skin, uncertain behavior
c. see also Neoplasm, skin, benign
d. turn to Appendix A to locate the correct code

11. Varicella is commonly known as _____.

a. cowpox
b. chickenpox
c. smallpox
d. duckpox

12. Tubercles, or small, rounded lesions and tissues that begin to resemble
cheese are some of the characteristics of what disease? _____
a. Tuberculosis
b. Leprosy
c. Whooping cough
d. Bubonic plague

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Medical Coding and Billing Specialist

13. Which is the most common form of post-transfusion hepatitis? _____

a. Hepatitis B
b. Hepatitis C
c. Hepatitis E
d. None of the above

14. Code 041.4 is for an infection called Escherichia coli, or _____.

a. Eaton’s agent
b. E. coli
c. Escherichia colicianism
d. Esch-coli

15. For a diagnosis of diabetes to be coded as uncontrolled, the physician

must _____.
a. indicate the patient is not taking insulin
b. specifically document it as such
c. document the medication is not effective
d. tell the medical coder directly

16. Untreated syphilis progresses through three clinical stages: _____.

a. primary, secondary and tertiary
b. principal, secondary and coexisting
c. first, second and third
d. I, II and III

17. Malignant neoplasms are grouped into the behavioral categories

of _____.
a. first, second and third
b. primary, secondary and carcinoma in situ
c. primary, secondary and tertiary
d. malignant, benign and carcinoma in situ

18. Category 286 codes for coagulation defect. Which is not an eponym
listed in this category? _____
a. Rosenthal’s disease
b. Owren’s disease
c. von Willebrand’s disease
d. Alzheimer’s disease

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19. Which is an important exception to the rules we’ve discussed for codes
included in Chapter 2 of the Tabular List? _____
a. Not all tumors that end in -oma are benign.
b. Not all malignant tumors are labeled as carcinomas or sarcomas.
c. Both a and b.
d. None of the above.

20. To accurately code category 042, you must _____.

a. be familiar with the Coding Guidelines in the front of your ICD-9-CM manual
b. know the patient’s medical history
c. understand all complications of this disease
d. apply a fourth- and fifth-digit subclassification

Choose the best diagnostic code(s) from the choices provided.

21. Carcinoma in situ of the colon _____

a. 230.3
b. 230.4
c. 153.9
d. 239.0

22. Bacterial culture indicates tuberculoma of brain _____

a. 013.24
b. 012.3
c. 013.34
d. 012.30

23. Adenocarcinoma involving both intrahepatic and extrahepatic

bile ducts _____
a. M8160/3
b. 156.9
c. 156.1
d. 197.8

24. Secondary malignant neoplasm of the larynx, with primary site not
identified _____
a. 197.3 161.9
b. 197.3 199.1
c. 161.9 199.1
d. 199.0 161.9

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Medical Coding and Billing Specialist

25. Diabetic coma, without insulin use _____

a. 250.3
b. 250.30
c. 250.31
d. 250.13

26. Enterobacter aerogenes of unspecified site _____

a. 127.4
b. 041.85
c. 041.89
d. 008.2

27. Addison’s disease _____

a. 255.41
b. 281.0
c. 017.6
d. 272.2

28. HIV infection, symptomatic _____

a. V08
b. 042
c. 42
d. 08

29. Office visit for an established patient _____

SUBJECTIVE
A 54-year-old female complains of fatigue and lack of motivation. Tires easily
and SOB upon exertion. Patient states her eating habits have not changed, but
she has been less active the past 6 months.
OBJECTIVE
Expanded problem focused exam performed.
ASSESSMENT
Obesity.
PLAN
Healthy diet and exercise recommended.

a. 278.00
b. 244.9
c. 278.01
d. 255.8

24-50 0205502LB03A-24-13
 ICD-9-CM Coding—From Infections to Blood Diseases

30. Pathology Report _____

SUBJECTIVE
Patient complains of leg pains, extreme thirst and frequent urination.
OBJECTIVE
Serum potassium 2.5 mEq/L.
ASSESSMENT
Hypokalemia.
PLAN
Give oral potassium supplement.

a. 729.5 783.5 788.41 276.8

b. 729.5 276.8
c. 276.8 729.5 783.5 788.41
d. 276.8

Endnote
1
2005 ICD-9-CM Professional for Physicians - Volumes 1 & 2, Salt Lake City, Utah: Ingenix, Inc. August 2004,
page 3, Volume 1

0205502LB03A-24-13 24-51
Medical Coding and Billing Specialist

Congratulations!
You have completed Lesson 24.

Drive
Terrific
n t !
Quality h me
l i s
o mp
A c c Learn
ing
Skillful

Do not wait to receive the results of your Quiz

before you move on.

24-52 0205502LB03A-24-13
 Lesson 25

Introduction to
ICD-9-CM
Medical Coding—
Terminology:
From Mental Disorders
Word Parts
to Circulatory System
 Step 1 Learning Objectives for Lesson 25
 When you have completed the instruction in this lesson, you will be trained to do the following:
 Assess mental disorders, diseases of the nervous system and sense organs
and diseases of the circulatory system.

 Explain the exclusions, inclusions and rules related to Chapters 5 through 7

of the Tabular List in the ICD-9-CM manual.

 Identify the diagnoses, outline the coding pathway and assign the final code
for documented disorders and diseases.

 Step 2 Lesson Preview

 Now that you’ve begun to practice coding medical conditions, you
have taken a big step toward your goal of becoming a medical coding
and billing specialist. You will move even further toward that goal
in this lesson, which introduces you to the codes in Chapters 5
through 7 of the ICD-9-CM manual’s Tabular List. These chapters
encompass the major disease categories of mental, behavioral and
neurodevelopmental disorders, diseases of the nervous system and
sense organs and diseases of the circulatory system.

Just as in the previous lesson, you’ll find a lot of detailed

information here. But just as before, you’ll have as much time
as you need to study the material and make sense of it. And This chapter introduces
as always, you can contact your instructor whenever you have you to the codes in
questions you need answered. Chapters 5 through 7 of
the ICD-9-CM manual’s
Again, we subdivide all the chapters in this lesson into discussions Tabular List.
about each section and refer you often to the Index to Diseases and
the Tabular List so you can see exactly what we’re talking about.
And we provide you with lots of practice exercises to allow you to
apply your coding skills as you learn.

0205502LB03A-25-13
Medical Coding and Billing Specialist

When you have completed this lesson, you will be more than half-way through all
the chapters of the Tabular List. So let’s get moving! Take a few deep breaths, relax,
and you’re ready to start learning how to code mental disorders.

To help make sure you don’t get confused as you code the practice
exercises and scenarios throughout the following ICD-9-CM coding
lesson, it’s important to keep in mind that we are focusing for now only
on ICD-9-CM codes—not CPT codes. You will see physician notes and
documentation about specific procedures in some of the scenarios we
use just because we want you to practice with authentic examples. But
remember that you will code only the diagnoses during these lessons—
you’ll have plenty of time and lots of practice combining procedural and
diagnostic codes in later lessons, after you’ve become more familiar and
comfortable with the ICD-9-CM codes.

 Step 3 Mental, Behavioral and Neurodevelopmental

Disorders (290-319)
 A mental disorder is any clinically significant behavioral or psychological
syndrome that is characterized by the presence of distressing symptoms or
significant impairment of function. Chapter 5 of the Tabular List includes the
diagnosis codes for a broad range of mental disorders. Specifically, the sections focus
on psychoses; neurotic, personality and other nonpsychotic mental disorders; and
intellectual disabilities. As before, we will discuss each section in detail to help you
build your knowledge of this subject.

Another widely used set of codes comes from the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, which
American Psychiatric Publishing, Inc. publishes. When you
assign codes for mental disorders, use both books as a
reference aid, but ultimately use the ICD-9-CM manual
to assign a code. As a student in this course, you do not
need the Diagnostic and Statistical Manual of Mental
Disorders. You will use the ICD-9-CM manual to assign
this type of diagnosis.

Psychoses (290-299) Chapter 5 of the Tabular List

Psychoses are mental disorders in which the person includes the diagnosis codes for a
demonstrates a loss of ego, boundaries or a gross broad range of mental disorders.
impairment in reality testing, with delusions or
prominent hallucinations. Turn to the Tabular List in
your ICD-9-CM manual and locate this section of Chapter 5.

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 ICD-9-CM Coding—From Mental Disorders to Circulatory System

Under the section heading, you will see EXCLUDES “intellectual disabilities.” You
are directed to use code categories 317 through 319 for that diagnosis. The “Psychoses”
section is further broken down into “Organic Psychotic Conditions (290-294)” and
“Other Psychoses (295-299).”

The code category for Organic Psychotic Conditions (290-294) INCLUDES

“psychotic organic brain syndrome.” It EXCLUDES “nonpsychotic syndromes of
organic etiology,” (310.0 through 310.9) and “psychoses classifiable to 295-298 and
without impairment of orientation, comprehension, calculation, learning capacity
and judgment, but associated with physical disease, injury, or condition affecting the
brain [e.g., following childbirth] (295.0-298.8).”

Category 290 codes dementias, which are characterized by a general loss of

intellectual abilities, involving impairment of memory, judgment and abstract
thinking, as well as changes in personality. You are instructed to code first the
associated neurological condition for category 290. This means that if a neurological
condition is documented together with dementia, that neurological condition will be
your principal diagnosis code, and the dementia will be your secondary diagnosis code.

Using your ICD-9-CM manual, let’s code uncomplicated senile dementia. First, go to
the Index to Diseases and locate the main term Dementia. The subterm is senile. You
will quickly find the code 290.0. Note this tentative code, and then turn to the Tabular
List to determine the highest level of specificity. Based on the information you find you
will assign 290.0 Senile dementia, uncomplicated as the correct code. Great job!

The other organic psychotic conditions in this section are caused by a chemical
imbalance in the patient. This imbalance may be the result of alcohol intoxication
or withdrawal, or it may represent disorders caused by consumption of drugs. This
category has many inclusions, exclusions and additional notes to assist you with
accurate coding. Be sure you use additional codes, when indicated, to identify drugs
and code underlying conditions.

Now that we’ve introduced you to organic psychotic conditions, let’s look at “Other
Psychoses (295-299)” to give you a better understanding of the category. If the
condition is documented, you are to use an additional code to identify any associated
physical disease, injury or condition affecting the brain with psychoses classifiable
to codes 295-298. These other psychotic conditions include schizophrenia, episodic
mood disorders, delusional disorders, other nonorganic psychoses and pervasive
developmental disorders.

Schizophrenic disorders, found in category 295, represent a group of

disorders with disturbances in thought, mood, sense of self and relationship to
the world. Schizophrenic disorders also include bizarre, purposeless behavior,
repetitious activity or inactivity. This category INCLUDES schizophrenia of the
types described in codes 295.0 through 295.9 occurring in children. The category
EXCLUDES childhood type schizophrenia (299.9) and infantile autism (299.0).
Category 295 requires a fifth-digit subclassification to describe the current condition
of the disorder.

0205502LB03A-25-13 25-3
Medical Coding and Billing Specialist

Review the following box, which identifies the fifth digits you will select from when
you code this category.

The following fifth-digit subclassification is for use with category 295:

0 unspecified
1 subchronic
2 chronic
3 subchronic with acute exacerbation
4 chronic with acute exacerbation
5 in remission

Code category 296 covers Episodic Mood Disorders that range from bipolar I
disorder to major depressive disorder. The fifth-digit subclassification for the
subcategories 296.0 through 296.6 indicates whether the disorder is unspecified,
mild, moderate, severe or in remission. Once again, take a closer look here at the
box, which identifies these fifth digits:

The following fifth digits are for use with categories 296.0-296.6:
0 unspecified
1 mild
2 moderate
3 severe, without mention of psychotic behavior
4 severe, specified as with psychotic behavior
5 in partial or unspecified remission
6 in full remission

Code category 297 Delusional disorders INCLUDES paranoid disorders

and EXCLUDES acute paranoid reaction (298.3), alcoholic jealousy or paranoid
state (291.5) and paranoid schizophrenia (295.3). A shared psychotic disorder
(297.3) is a mental disorder two people share. Because of their close relationship
and shared experiences, the first person with the delusional disorder convinces the
second person to accept the delusions.

Now that you have an initial understanding of other psychotic conditions, let’s get
some practice coding them!

SUBJECTIVE
A patient presents with sadness and low self-esteem. Patient notes her
normal sleep is now “interrupted sleep.” The patient is very critical of herself
and feels inadequate. The patient denies suicidal thoughts.
OBJECTIVE
Detailed physical exam is normal.
ASSESSMENT
The doctor’s impression is the patient has psychotic depression.
PLAN
Antidepressants will be prescribed.

25-4 0205502LB03A-25-13
 ICD-9-CM Coding—From Mental Disorders to Circulatory System

As the medical coding and billing specialist, would you choose depression or
psychosis as the main term? A quick look at each term in the Index to Diseases
indicates that either path will result in the same code. Let’s use Psychosis as the
main term and depressive as the subterm. Using that pathway, the Index to Diseases
notes to “see also Psychosis, affective.” Refer to Lesson 23 and note that see also
indicates that additional information about the term and code is available to you
under the referenced term in the Index to Diseases. After you review the information
provided, your conclusion should be that you’re on the right track with the original
pathway; so return to Psychosis, depressive in the Index to Diseases and note the
tentative code of 296.2  . Then turn to the Tabular List to determine the highest
level of specificity. You’ll note that code 296.2 describes major depressive disorder,
single episode. Psychotic depression is included as a subterm under that description.
To determine the fifth-digit subclassification for the code, you must determine
whether the doctor documented mild, moderate, severe or in remission. This
information is not documented, so you must select the fifth-digit 0 for “unspecified.”
You will assign code 296.20 Major depressive disorder, single episode,
unspecified for the final diagnosis.

Neurotic Disorders, Personality Disorders, and Other

Nonpsychotic Mental Disorders (300-316)
As you may be able to tell from the title of this section, it contains a variety of disorders,
dependencies and disturbances. Anxiety, personality disorders, sexual and gender-identity
disorders, alcohol and drug dependency, nondependent abuse of drugs and other special
symptoms or syndromes not elsewhere classified are covered in this one section. We will
discuss the fifth-digit subclassification, but you will discover important information on your
own as you review the EXCLUDES information and additional notes in this section.

In the categories 303 Alcohol dependence syndrome, 304 Drug dependence and
305 Nondependent abuse of drugs, note the boxes for the fifth-digit subclassifications
that relate to each category. Let’s take a look at examples from each subclassification and
do some coding practice so that you fully understand the meaning of the various fifth-
digit terms. The fifth-digit options are the same for each of these codes. Use the following
box to select the appropriate fifth digit as you code these examples.

0 unspecified
1 continuous
2 episodic
3 in remission

Fifth-Digit 0—Unspecified
Now try your hand at coding the following: A male of unknown age is brought
unconscious to the ED. Once the patient has regained consciousness, the physician
obtains a problem focused history and performs an expanded problem focused exam.
The physician recommends detoxification. The patient refuses treatment and leaves
AMA (against medical advice). He is diagnosed with chronic alcoholism.

0205502LB03A-25-13 25-5
Medical Coding and Billing Specialist

To code this condition, locate the main term Alcoholism in the Index to Diseases.
The subterm chronic suggests that 303.9  is tentatively the correct code. Now
turn to the Tabular List to determine the highest level of specificity. You do not
know whether this patient’s dependency is continuous, episodic, or in remission,
so you must code to “unspecified,” or 0, for the fifth-digit subclassification. You will
assign 303.90 Alcohol dependence syndrome, Other and unspecified alcohol
dependence, unspecified as the accurate code for this scenario.

Fifth-Digit 1—Continuous
Here’s the next example to code: A 42-year-old female was involved in a car accident
six months ago and suffers from whiplash. At the time of the accident, she was
prescribed 1 to 2 tablets of Percodan to be taken every six hours as needed for pain.
She is being seen by her physician for a prescription refill. The physician performs a
detailed exam. He strongly advises the patient to find an alternative method for pain
relief. The patient decides to schedule another visit in one month. The physician’s
assessment for this encounter is continuous dependency of Percodan.

To code this condition, use the coding pathway Dependence, Percodan. Note the
tentative code of 304.0  in the Index to Diseases, and then turn to the Tabular List
to determine the highest level of specificity. Based on the physician’s notes, the fifth
digit you will use is 1 for “continuous.” So you assign code 304.01 Drug dependence,
Opioid type dependence, continuous as the correct code for this condition.

Fifth-Digit 2—Episodic
You’re getting the hang of things now, aren’t you? See how quickly you can
determine the correct code for the following example: A 21-year-old college student
is a new patient in the clinic. She admits the use of cocaine during her “finals week,”
believing its use increases her performance, confidence and energy. Now that her
exams are over, she reports problems with insomnia related to the episodic use of
the drug. After a problem focused exam the patient is encouraged to discontinue use
of the drug. The patient is diagnosed with episodic cocaine abuse.

To code this condition, find the main term Abuse in the Index to Diseases. The subterms
drugs, nondependent, cocaine type provide the tentative code of 305.6  . Now turn
to the Tabular List to determine the highest level of specificity. Given all that you see
here, including the fifth-digit options, you will assign code 305.62 Nondependent
abuse of drugs, Cocaine abuse, episodic based on the documentation of “episodic”
in the notes.

Fifth-Digit 3—In Remission

Okay, here’s the last example for you to code in this group: A 36-year-old patient has
a history of sedative abuse but has been in remission for six months.

To code this condition, locate Abuse as the main term in the Index to Diseases. The
subterms of drugs, nondependent and sedative provide you the tentative code of 305.4  .

25-6 0205502LB03A-25-13
 ICD-9-CM Coding—From Mental Disorders to Circulatory System

Note the code and find it in the Tabular List to determine the highest level of specificity.
Because remission is documented, you determine that the fifth-digit subclassification is
3, and you assign code 305.43 Nondependent abuse of drugs, Sedative, hypnotic or
anxiolytic abuse, in remission as the correct choice.

Intellectual Disabilities (317-319)

Intellectual disabilities are characterized by significantly subaverage general
intellectual functioning that is associated with impairments in adaptive behavior,
and that manifests during the child’s developmental period. The Tabular List
instructs you to use additional code(s) to identify any associated psychiatric or
physical conditions if they are documented. The intellectual disabilities diagnosis
can be classified as mild, moderate, severe, profound or unspecified. IQ levels are
indicated in the ICD-9-CM with codes to correlate with each classification.

This completes your introduction to the codes in Chapter 5 of the Tabular List.
Before we move ahead to the contents of Chapter 6, complete the following exercises
to review what you’ve learned.

 Step 4 Practice Exercise 25-1

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Alcoholic delirium
ICD-9-CM code: _______________________________

2. Catatonic stupor
ICD-9-CM code: _______________________________

3. Acute hysterical psychosis

ICD-9-CM code: _______________________________

4. Obsessive-compulsive disorder
ICD-9-CM code: _______________________________

5. Anorexia nervosa
ICD-9-CM code: _______________________________

6. Kleptomania
ICD-9-CM code: _______________________________

7. Mild mental subnormality

ICD-9-CM code: _______________________________

0205502LB03A-25-13 25-7
Medical Coding and Billing Specialist

Use the following information to complete the CMS-1500 that follows.

8. ICD-9-CM Coding Challenge

Dwight Harrison, MD Leslie Jones, MD Clifford Phillips, MD

NPI: 6574900497 NPI: 0405891109 NPI: 0275695402
Provider for Medicaid and Provider for Medicare, Provider for Medicaid
Western Workers Insurance Mutual Insurance and Blue Cross
  
 Medical Care Center 
 100 South Main 
 Yourtown, CO 80000 
 (970) 555-1111 

Patient Information
Name Kami Reynolds Date of Birth June 25, 1997
Address 4575 Dixon Court Apt 7 Sex F Marital Status single
City Youngstown State CO
ZIP 80004
Home Phone 970-555-6996

Employment Information
Name of Employer
Occupation
Student Status X Full time Part time

Insurance Information
Primary Insurance Secondary Insurance
Name Medicaid Name none
ID# 521-00-3333 ID#
Group# Group#
Address PO Box 1461 Address
City Denver City
State CO ZIP 80203 State ZIP
Primary Insured Name Kami Reynolds Secondary Insured Name
Relation to Patient Self Relation to Patient
Employer Employer
I authorize the release of any information including diagnosis and I authorize the release of any information including diagnosis
treatment. I authorize my insurance carrier to pay directly to the and treatment. I authorize my insurance carrier to pay directly
doctor any benefits otherwise payable to me. to the doctor any benefits otherwise payable to me.

Nicole Reynolds
Signature of patient (or parent of minor child)
Signature of patient (or parent of minor child)

Physician signature: Clifford Phillips MD

Group NPI: 0665544004
EIN: 99-0000009
CLIA# CM8402

DateofService 5/1/20XX
Diagnosis Procedure Charge
99213 Est. Patient Level 3 $63.00
Today’s Charge $63.00
Cash/Check $0.00
Balance $63.00

25-8 0205502LB03A-25-13
 ICD-9-CM Coding—From Mental Disorders to Circulatory System

Kami Reynolds
DOB June 25, 1997
Date of Service 5/1/XX

SUBJECTIVE
This patient is brought in by her mother because of a change in the
daughter’s behavior. The mother notes hyperactivity, outbursts and
over-involvement in activities. Patient notes she has been sleeping
little and has been involved in sexual promiscuity. She denies
medication, recreational or OTC drugs. Family history includes
maternal bipolar disorder.

OBJECTIVE
An expanded problem focused physical exam does not indicate physical
causes for these symptoms. Lab results indicate the thyroid is normal.

ASSESSMENT
Bipolar disorder.

PLAN
Recommend getting more sleep. Patient is prescribed lithium and
encouraged to join a support group.

0205502LB03A-25-13 25-9
Medical Coding and Billing Specialist

1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
M F
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
Self Spouse Child Other

CITY STATE 8. PATIENT STATUS CITY STATE

Single Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
Employed
Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State) b. EMPLOYER’S NAME OR SCHOOL NAME
M F YES NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED DATE SIGNED

14. DATE OF CURRENT ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
INJURY (Accident) OR GIVE FIRST DATE
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

17b. NPI FROM TO

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. . 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
FROM TO PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
YES NO $ $ $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 33. BILLING PROVIDER INFO & PH #
DEGREES OR CREDENTIALS (I certify that the statements on the 32. SERVICE FACILITY LOCATION INFORMATION
reverse apply to this bill and are made a part thereof.)

SIGNED DATE a. b. a. b.

25-10 0205502LB03A-25-13
 ICD-9-CM Coding—From Mental Disorders to Circulatory System

 Step 5 Review Practice Exercise 25-1

 Check your answers with the Answer Key at the back of this book. Correct
any mistakes you may have made.

 Step 6 Diseases of the Nervous System and

Sense Organs (320-389), Part 1
 Chapter 6 of the ICD-9-CM manual’s Tabular List contains codes that pertain to
the nervous system and sense organs. The nervous system regulates almost every
activity in the body. The central and peripheral nervous systems comprise the
nervous system. The central nervous system is composed of the brain and spinal
cord. In this step, we will discuss this system and each of its sections, which include
inflammatory diseases, hereditary and degenerative diseases and other disorders of
the central nervous system. We will then discuss the disorders of the peripheral
nervous system, which consist of the nerves and ganglia outside the brain and
spinal cord. Finally, later in the lesson, we will identify the diagnostic process that
deals with the sense organs, specifically of the eye and the ear.

Peripheral Nervous System (PNS) Central Nervous System (CNS)

Cerebrum

Nerve plexus Brain

Pituitary Cerebellum
gland Medulla
Cranial oblongata
nerves
Spinal cord

Spinal
nerves

Nerve plexus

Sagittal View Anterior View

Overview
OverviewofofNeurologic
neurologicSystem
system Anatomic
anatomic Divisions
divisions

0205502LB03A-25-13 25-11
Medical Coding and Billing Specialist

Inflammatory Diseases of the Central Nervous

System (320-326)
In this section you will find diagnosis codes for meningitis, encephalitis, abscesses,
phlebitis and thrombophlebitis, as well as codes for the late effects of intracranial
abscess or pyogenic infection. This section lists many INCLUDES , EXCLUDES and
additional notes that will assist you in accurate coding of these disease diagnoses.

Meningitis is an inflammation of the meninges, usually by either a bacterium

or a virus. Meninges are the three membranes, the dura mater, the pia mater
and the arachnoid, that cover the brain and spinal cord. Open your ICD-9-CM
manual to the Tabular List, code category 320, and note that this category is
specific to bacterial meningitis. This section lists many INCLUDES listed under
the code description. All of the infections that cause inflammation are bacterial,
as well. Subcategory 320.7 directs you to first code the underlying diseases, and
then, to assist you in coding, it provides a list of some diseases. Move to category
321, and you will note that diseases in this category are caused by organisms
other than bacteria. Another noteworthy item is that each subcategory of code
321 directs you to code first the underlying diseases. Finally, you should use code
category 322 if no organism is specified as the cause of meningitis.

You will use code category 323 for the conditions of encephalitis, myelitis and
encephalomyelitis. Note that each of these conditions ends with “itis.” You
know from your terminology lessons that this suffix means “inflammation of.”
Encephalitis is inflammation of the brain. Myelitis is inflammation of the
spinal cord and of the bone marrow. Encephalomyelitis is inflammation of the
brain and spinal cord. The Tabular List instructs you to code first the underlying
disease in this category, as well.

Now that you are aware of the INCLUDES , EXCLUDES and additional notes in
this section, it’s time to give coding a try! Code for a diagnosis of meningitis due to
whooping cough. Open your ICD-9-CM manual to the Index to Diseases, and locate
the main term Meningitis. As you look down the list of subterms, you will find due
to. This sounds like a good path to take, so let’s continue. Under that subterm, you
will find whooping cough, followed by codes 033.9 [320.7]. Remember from Lesson
23 that the slanted brackets indicate that another code is required in addition
to the first code listed. You must record both codes, in the order they are given.
Remember—do not include the slanted brackets when you record the second
code. Note these tentative codes, and then turn to the Tabular List to determine
the highest level of specificity. You will assign codes 033.9 Whooping cough,
unspecified organism and 320.7 Meningitis in other bacterial diseases
classified elsewhere as the correct codes for this condition. You’re doing well!

The next section, Organic sleep disorders (327), is fairly straightforward to

code, so let’s move on to the next section.

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 ICD-9-CM Coding—From Mental Disorders to Circulatory System

Hereditary and Degenerative Diseases of the Central

Nervous System (330-337)
The term neurodegenerative disease is a catch-all phrase that describes several
poorly understood diseases that affect only the central nervous system (CNS).
The etiology of these diseases is unknown, and they are all incurable, although
some are treatable. Easily recognized symptoms often lead to the diagnosis of
neurodegenerative disease. Sometimes, however, patients do not display all the
common clinical features of a disease, so the diagnosis can be made only by the
process of elimination relative to other CNS diseases. Before we discuss some of
the diseases you will find within this section, review the Tabular List to note the
inclusions, exclusions, notes and the many eponyms provided to assist you with
accurate coding. Remember that eponyms are diseases named for persons. Four
neurodegenerative diseases worth a closer look are Alzheimer’s disease, Parkinson’s
disease, Huntington’s disease and amyotrophic lateral sclerosis (known by many
people as ALS or Lou Gehrig’s disease, as discussed later).

As the overall population of the United States ages, awareness of and the
predominance of Alzheimer’s disease grows. Alzheimer’s disease is a disease of
diffuse atrophy throughout the cerebral cortex. The disease causes a progressive
decline in intellectual and physical functions, including memory loss, personality
changes and profound dementia. Technically speaking, Alzheimer’s disease is a form
of dementia, and its cause is unknown. We discussed dementia earlier in this lesson,
so let’s apply what you’ve learned to see how that information helps you in the
coding process.

Consider that you are the medical coding specialist for a nursing home. You are to
code the following dictation:

SUBJECTIVE
A 65-year-old rest home resident is seen for evaluation. Patient complains
of memory disturbance, and the staff notes personality changes but no
behavioral disturbances. The physician reviews the patient’s history from
the medical records.
OBJECTIVE
A detailed exam is performed.
ASSESSMENT
The patient is diagnosed with Alzheimer’s dementia.
PLAN
The patient will be monitored by the staff for signs of increased agitation.

0205502LB03A-25-13 25-13
Medical Coding and Billing Specialist

To code this condition, would you use Alzheimer’s or dementia as the main term?
Let’s try Dementia as the main term and Alzheimer’s as the subterm. Turn to
the Index to Diseases and locate this coding pathway. You are instructed to “see
Alzheimer’s dementia.” We chose the wrong coding pathway, but you have directions
now! We will use Alzheimer’s as the main term and dementia as the subterm. The
coding pathway of Alzheimer’s, dementia gives you a choice of “with or without
behavioral disturbances.” According to the notes, the staff sees changes in the
patient’s personality, but no behavioral disturbances. So you will note a tentative
code without behavioral disturbances, which indicates 331.0 [294.10]. Remember
that the slanted brackets indicate that another code is required in addition to the
first code listed. You must record both codes, in the order as they are given, but you
do not include the slanted brackets when recording the second code. Now turn to the
Tabular List with these tentative codes to determine the highest level of specificity.
Based on the information you find there, you will assign codes 331.0 Alzheimer’s
disease and 294.10 Dementia in conditions classified elsewhere without
behavioral disturbance as the final diagnosis codes for this encounter.

Parkinson’s disease is a well-known and relatively common disease that

creates movement disorders and pathologic changes in the midbrain that affect
the involuntary muscle system. This disease results in decreased numbers of
dopaminergic neurons in the brain. These neurons produce dopamine, and many
symptoms of Parkinson’s are related to the brain’s underproduction of this chemical.
For this reason, administration of the drug L-dopa has been known to temporarily
reduce the effects of Parkinson’s in a minority of patients. Category 332 is where you
will find the specific codes for this disease.

Huntington’s disease, coded in category 333, is a genetic disease characterized

by chronic progressive mental deterioration, twisting movements of the face,
limbs and body. Facial movements are affected, which can cause aspiration and
malnutrition. Walking becomes impossible due to deterioration of gait. This
disease does not usually appear or show symptoms until individuals are in the
middle of their lives. Once the symptoms appear, the course of the disease is rapid.
Death usually occurs 10 to 20 years after the onset of symptoms.

Amyotrophic lateral sclerosis (ALS) is a disease that became well-known

when baseball player Lou Gehrig contracted it. Since then, the disease has
commonly been referred to as Lou Gehrig’s disease. Involuntary twitching
of the hand muscles is a common early symptom, and the disease can lead to
slurring of speech in advanced cases. In the end, patients are immobilized, and
death usually results from paralysis of the respiratory muscles. The ICD-9-CM
code for this disease is 335.20. To locate the code in the Index to Diseases, you
can follow many different coding pathways:

Main term: Disease; subterm: Lou Gehrig’s

Main term: Lou Gehrig’s disease
Main term: Sclerosis; subterm: amyotrophic (lateral)
Main term: Amyotrophia; subterm: sclerosis (lateral)

25-14 0205502LB03A-25-13
 ICD-9-CM Coding—From Mental Disorders to Circulatory System

Other Headache Syndromes (339)

In a later lesson, we will discuss how to code a headache when it’s a symptom of an
unconfirmed diagnosis or an uncertain condition. However, a headache may be the
problem, not just the symptom of another condition. In this case, you will code from
category 339, Other headache syndromes. These conditions include cluster, tension,
post-traumatic, drug-induced, complicated and other specified headache syndromes.

A cluster headache is one of the most painful types of headache, which occurs in
cyclical patterns, or clusters. This type of headache is rare, although it is more
common in men and it’s most common among those between ages 20 and 40. Based
on the length of the cluster periods and the remission periods, the International
Headache Society has classified cluster headache into two types:

Episodic—In this form, cluster headache occurs at least daily for one week to one
year, followed by a pain-free remission period lasting at least one month before
another cluster period develops.

Chronic—In this form, cluster headache occurs daily for more than a year with no
remission or with pain-free periods lasting less than one month.

The most common headache is the tension headache. A tension headache often
feels like a tight band is around the head. It may be triggered by neck strain
or eyestrain. The tension headache can be classified as episodic, chronic or
unspecified. Turn in the Tabular List to 339.1, Tension type headache and review
that this code EXCLUDES “tension headache NOS” and “tension headaches
related to psychological factors.” Most tension headaches are easily treated with
over-the-counter medications, including aspirin, ibuprofen and acetaminophen.

If you’ve been taking pain medication often, even common medications such as
aspirin, acetaminophen and ibuprofen, the drugs may actually be contributing to your
headaches rather than easing them. Drug induced headaches or rebound headaches
may be dull, achy, throbbing or pounding and are caused by medication overuse. The
only way to stop rebound headaches is to reduce or stop taking the pain medication
that’s causing them.

Other Disorders of the Central Nervous System (340-349)

The disorders you will find in this section are varied. Multiple sclerosis,
hemiplegia, epilepsy, migraine and encephalopathy are among the many disorders
included here. As before, we will cover some important items in this section, but
when you are coding, be sure to read the inclusions, exclusions and additional
notes in the Tabular List so you can code the diagnoses accurately.

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system.

This relatively common disease affects approximately one out of every 1,000 people
in the United States. MS affects mostly people from 20 years to 45 years of age, and
it is the number one neurological disease in young adults.

0205502LB03A-25-13 25-15
Medical Coding and Billing Specialist

MS affects women about twice as often as it does men. The cause of MS is completely
unknown, and it currently has no cure. This disease involves both sensory and motor
abnormalities. The course of multiple sclerosis is chronic, and it is characterized by
periods of intense symptoms followed by periods of remission. Symptoms involving
the senses include blurred vision, a loss of the feeling of touch and unusual tingling
sensations. The physical symptoms include weakness, difficulty or unsteadiness in
walking and urinary- and sphincter-control problems. Currently MS can be treated
with interferon drugs, which help reduce the frequency of symptoms.

Now turn to code category 342 Hemiplegia and hemiparesis in the Tabular List,
and locate the fifth-digit subclassification box. You will find information like the box
on the page that follows.

The following fifth digits are for use with codes 342.0-342.9:
0 affecting unspecified side
1 affecting dominant side
2 affecting nondominant side

You will use these fifth digits to identify the side of the body affected by the
hemiplegia, and they require some definition. Your dominant side is the side of
the body you use primarily for activities of daily living (ADLs). For example, a
right-handed person is right-side dominant. Usually the doctor will include in
the dictation which side was affected, as well as whether that side is dominant
or nondominant. If the doctor does not include this information, you will code to
“unspecified.” You will also see reference to the “dominant side,” “nondominant side”
and “unspecified side” in subcategories 344.3 and 344.4 for monoplegia of the lower
and upper limbs.

Epilepsy is a brain disorder characterized by uncontrolled electrical discharges of

neurons that interrupt normal function in the brain. Individuals with epilepsy may
experience brief periods of unconsciousness, starring spells or even convulsions.
Although epilepsy is a chronic condition, it does not usually get worse over time.
People with epilepsy can expect to live a normal life span. There is no cure for
epilepsy, but seizure-preventing medication can control those symptoms in a
majority of persons with the disease. The condition for those individuals who do not
respond to current medications is termed intractable. You can see this term in the
box for fifth-digit subclassification in the 345 Epilepsy and recurrent seizures
code category. If the term intractable is not specified, you can determine by the
documented medication which digit would be most appropriate.

25-16 0205502LB03A-25-13
 ICD-9-CM Coding—From Mental Disorders to Circulatory System

Turn in the Tabular list to category 346 Migraine. You will note this category
excludes headaches not otherwise specified, which you’ll use 784.0, as well as the
headache syndromes, codes 339.00 through 339.89. You will note a box similar to the
one that follows:

The following fifth digit subclassification is for use with category 346:
0 without mention of intractable migraine without mention of
status migrainosus
1 with intractable migraine, so stated without mention of status
migrainosus
2 without mention of intractable migraine with status migrainosus
3 with intractable migraine, so stated, with status migrainousus

For you to code the fifth-digits 1 or 3, the physician must specifically document that
the patient does not respond to current medications related to the disease. If that is
not documented you will use either 0 or 2 as the fifth digit. Status migrainosus is
a debilitating migraine attack lasting for 72 hours or longer. Again, the physician
must clearly document status migrainosus if the fifth digit is a 2 or 3.

Migraines can be classified as with or without an aura. A migraine with aura, or

classic migraine, is characterized by visual disturbances such as flashes of light,
zigzagging patterns or even blind spots. These warning symptoms may occur
anywhere from a few minutes to 24 hours before the headache. Migraines without
aura are also known as common migraines. Remember, if the documentation only
provides “migraine” as the diagnosis, you’ll code 346.90 Migraine, unspecified,
without mention of intractable migraine without mention of status
migrainosus as the final code.

Time for some form coding practice: You are the medical coding and billing specialist
for emergency physicians, and you are to code the following dictation:

SUBJECTIVE
A 55-year-old female is seen in the emergency department complaining of
nausea, vomiting, and an intense headache. She experienced flashes of
light prior to onset of symptoms.
OBJECTIVE
An expanded problem focused exam is performed.
ASSESSMENT
The impression is that the patient is suffering from a classic migraine.
PLAN
The doctor suggests OTC (over-the-counter) medication and a follow-up with
the patient’s primary provider.

0205502LB03A-25-13 25-17
Medical Coding and Billing Specialist

The patient presented with symptoms of nausea, vomiting and a headache. You do
not code symptoms when a final diagnosis is provided. Therefore, you will begin in the
Index to Diseases with the coding pathway of Migraine, classic. Note the tentative
code of 346.0  and then turn to the Tabular List to determine the highest level
of specificity. The doctor does not indicate whether the patient is currently taking
medication for this condition and status migrainosus is not documented. You will
assign the final diagnosis code of 346.00 Migraine with aura, without mention
of intractable migraine without mention of status migrainosus.

Disorders of the Peripheral Nervous System (350-359)

Now that you have a basic understanding of the central nervous
when
system (CNS), let’s turn to the peripheral nervous you code
system.
Remember that the CNS is composed of the brain and the
indicated with
spinal cord, and that the peripheral nervous systemor 359.5
consists of the nerves and ganglia outside the brain andfirst.
disease
spinal cord. The peripheral nervous system section
includes codes for disorders and diseases of theultnerves,
of the
muscles and the combination of nerves and muscles,
neath the
such as carpal tunnel syndrome, myasthenia gravisnarrow
and muscular dystrophy, among others. You will s find
many eponyms in this section of the Tabular List.
y
Once again, remember that eponyms are diseases
named for persons. This section also has many
INCLUDES and EXCLUDES for you to be
aware of when you code from it. If an underlying
disease is indicated with codes 357.1 through
357.4, 358.1, or 359.5 through 359.6, you must
code that disease first.

Carpal tunnel syndrome is the result of the

compression of the median nerve beneath the
transverse carpal ligament within the narrow
confines of the carpal tunnel, which is located at
the wrist. A physician may diagnose a patient
with carpal tunnel syndrome by having her
hold her wrist back in an acute bent position
for 60 seconds. If this results in pain, tingling,
numbness and burning sensations in the
palmar surface of the thumb, the index finger,
the middle finger and part of the ring finger,
it is called a positive Phalen’s sign. One
treatment for this condition consists of resting
the hand and wrist for a period of time,
avoiding activities that may aggravate the
symptoms. The wrist may be splinted by the Source: Dorland’s Illustrated Medical Dictionary.
physician to avoid movement that might (1994). W.B. Saunders Company: Philadelphia, PA.
cause further damage to the nerves.

25-18 0205502LB03A-25-13
 ICD-9-CM Coding—From Mental Disorders to Circulatory System

To code this condition, use the coding pathway of Syndrome, carpal tunnel in the Index
to Diseases. Note 354.0 as the tentative code, and then turn to the Tabular List to
determine the highest level of specificity. Based on the information you find, you can
confidently assign code 354.0 Carpal tunnel syndrome for the condition.

Myasthenia gravis (MG) is a disease of the neuromuscular function characterized

by fluctuating weakness of certain skeletal muscle groups. It is an autoimmune
process that affects the neuromuscular junction by impairing muscle contraction.
The cause of MG is unknown. The symptoms of this disease involve fatigue of
voluntary muscles. Because the facial muscles are often affected, many persons
with this condition experience drooping eyelids, fatigue while reading or double
vision. The disease tends to spread first to the upper muscles, especially the eye,
face, lips, tongue, throat and neck. Eventually, MG spreads to the entire muscular
system, causing immobility. Death often results from paralysis of the respiratory
muscles and the diaphragm. You can locate code 358.00 for this condition in the
Index to Diseases by selecting the main term Myasthenia and the subterm gravis. If
you try to find the code using Gravis as the main term, you will be directed to “see
condition,” which is myasthenia.

Let’s pause here so you can take a few deep breaths and then review the information
from this section to see how well you understand all the details. We’ll continue with
the next section of the Tabular List and eye disorders after you have completed
Practice Exercise 25-2.

 Step 7 Practice Exercise 25-2

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Staphylococcal meningitis
ICD-9-CM code: _______________________________

2. Tay-Sachs disease
ICD-9-CM code: _______________________________

3. Spasmodic torticollis
ICD-9-CM code: _______________________________

4. Spastic hemiplegia affecting the dominant side

ICD-9-CM code: _______________________________

5. Intractable grand mal epilepsy

ICD-9-CM code: _______________________________

6. Bell’s palsy
ICD-9-CM code: _______________________________

0205502LB03A-25-13 25-19
Medical Coding and Billing Specialist

Use the following information to complete the CMS-1500 that follows.

7. ICD-9-CM Coding/Billing Challenge

FRONT RANGE FAMILY CARE __X___ Greg Stephen, MD NPI: 0267679942

1800 Circle Court _______ Donald Milford, MD NPI: 0810998051
Yourtown, CO 80000 _______ Douglas Smart, MD NPI: 0144878804
(970) 555-3344 Group NPI: 0881099885
Patient Information
Name Cathy Harrison Date of Birth August 9, 1967
Address 2419 Zendt Drive Sex F Marital Status Married
City Anytown State CO
ZIP 80000
Home Phone (970) 555-2112

Employment Information
Name of Employer Sandy’s Nails
Address 452 Link Lane
City Anytown State CO
ZIP 80000
Phone (970) 555-1397
Occupation receptionist
Student Full time part time If minor, name of school

Insurance Information
Primary Insurance Secondary Insurance
Name Blue Cross of Wyoming Name none
ID# 641-00-0000 ID#
Group# GE54002 Group#
Address PO Box 456 Address
City Casper City
State WY ZIP 82002 State ZIP
Primary Insured Name Tom Harrison Secondary Insured Name
Relation to Patient Spouse Relation to Patient
DOB 08-02-59 DOB
Employer Front Range Auto Sales Employer
I authorize the release of any information including diagnosis and I authorize the release of any information including diagnosis
treatment. I authorize my insurance carrier to pay directly to the and treatment. I authorize my insurance carrier to pay directly
doctor any benefits otherwise payable to me. to the doctor any benefits otherwise payable to me.

Tom Harrison Signature of patient (or parent of minor child)

Signature of patient (or parent of minor child)

Physician signature: Greg Stephen MD

SSN: 700-07-0007
EIN: 66-6000600
Participating Provider for: Blue Cross, HMO and Mutual Life

Date of Service 3/19/XX
Diagnosis Procedure Charge
99242 Consultation, level 2 $102.00

Today’s Charge $102.00

Cash/Check $20.00
Balance $82.00

25-20 0205502LB03A-25-13
 ICD-9-CM Coding—From Mental Disorders to Circulatory System

Cathy Harrison
DOB 8/9/1967
Date of Service 3/19/XX
Referred by Carolyn Hooper, MD
NPI: 0188123456

SUBJECTIVE
The patient is seen for an office consultation to confirm her physician’s
diagnosis of multiple sclerosis. Patient notes that tingling sensations
and weakness in her legs have increased.

OBJECTIVE
The patient history and recent MRI provided by her physician
are reviewed by the neurologist. An expanded problem focused
examination is performed.

ASSESSMENT
The neurologist confirms the diagnosis of multiple sclerosis.

PLAN
The patient is prescribed a 2-week course of prednisone to reduce
her current symptoms. She was also given information on current
injectable medications that could reduce the frequency of her
exacerbations. A follow-up appointment is to be scheduled to discuss
long-term treatment of her MS. A copy of the consultation notes will be
sent to her primary care provider.

0205502LB03A-25-13 25-21
Medical Coding and Billing Specialist

1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
M F
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
Self Spouse Child Other

CITY STATE 8. PATIENT STATUS CITY STATE

Single Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
Employed
Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State) b. EMPLOYER’S NAME OR SCHOOL NAME
M F YES NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED DATE SIGNED

14. DATE OF CURRENT ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
INJURY (Accident) OR GIVE FIRST DATE
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

17b. NPI FROM TO

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. . 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
FROM TO PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
YES NO $ $ $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 33. BILLING PROVIDER INFO & PH #
DEGREES OR CREDENTIALS (I certify that the statements on the 32. SERVICE FACILITY LOCATION INFORMATION
reverse apply to this bill and are made a part thereof.)

SIGNED DATE a. b. a. b.

25-22 0205502LB03A-25-13
 ICD-9-CM Coding—From Mental Disorders to Circulatory System

 Step 8 Review Practice Exercise 25-2

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may may have made.

 Step 9 Diseases of the Nervous System and

Sense Organs (320-389), Part 2
 We’re now ready to discuss the diagnosis codes that pertain to diseases and
conditions related to the sense organs. As noted earlier, our focus will be on
disorders of the eye and the ear.

Disorders of the Eye and Adnexa (360-379)

This section contains codes for disorders of the eye, including the lids and other
accessory organs of the eye. You are directed to use an additional external cause
code, if applicable, to identify the cause of the eye condition. In this section, you will
find codes for disorders of the globe, retina, choroid and iris. You will find diseases
such as glaucoma and cataracts. Visual disturbances and blindness are also covered.
And then you will discover many diseases that pertain to the appendages of the eye,
such as the conjunctiva and optic nerves.

In this section, you will note that the code description is at the highest level of
specificity—in other words, there are no fifth-digit subclassification boxes to
consider. A few codes are manifestations of other diseases, and the text directs you
to first code the underlying disease. We will include some of the information from the
Tabular List in this step, but you will want to review the details carefully on your
own when you are coding from this section.

Turn to the Tabular List and locate code category 360, which contains codes for
disorders of the globe. The globe of the eye is also referred to as the eyeball. The
first disorder you encounter in subcategories 360.0 and 360.1 is endophthalmitis,
which is an inflammation of the tissues within the eyeball. Note subcategories 360.5
and 360.6 for codes pertaining to retained (old) foreign bodies, and you are to use
an additional code to identify the foreign body. Code 360.5 EXCLUDES current
penetrating injury with magnetic foreign body, while code 360.6 EXCLUDES
nonmagnetic foreign bodies. Instead, you will use a code in the 800 range for current
injuries. These subcategories are specifically for those foreign bodies that have been
present for a while and are not likely to be removed.

0205502LB03A-25-13 25-23
Medical Coding and Billing Specialist

Anatomyand
Anatomy andBasic
basicPhysiology
physiologyofofthe
theGlobe
globe

Categories 361 and 362 supply diagnostic codes for the retina. This light-sensitive
membrane forms the innermost layer of the eyeball. When you have a retinal
detachment, the light-sensitive layer at the back of the eye separates from the
blood supply, causing disruption to vision. Retinopathy is a noninflammatory
degenerative disease of the retina. There are two types of background
retinopathy; one is designated as a manifestation from diabetes, and one is not.
Persons who have diabetes for a long period become susceptible to retinal changes
that may lead to this degenerative disease of the retina. If this is the case, you are
directed to code the diabetes first and use the diabetic retinopathy code 362.01
as the secondary code. If diabetes is not documented, code 362.10 for background
retinopathy, is applied.

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 ICD-9-CM Coding—From Mental Disorders to Circulatory System

Try your hand at the following scenario, and see how well you do:

PRESENTING PROBLEM
The patient notes flashes of light, followed by a sensation of curtain moving
across the eye. Diagnosed with partial retinal detachment.
PROCEDURE
REPAIR OF RETINAL DETACHMENT.
The sclera is explored, and stay sutures are placed under the rectus muscles
to allow access to the surgical site. Cryotherapy (freezing retinal tissues to
seal them) was used. Incisions are repaired by layered closures. A topical
antibiotic is applied.
POSTOPERATIVE DIAGNOSIS
Partial retinal detachment, single defect.

To code this condition, determine the Index to Diseases coding pathway. You will
select the main term Detachment and the subterms retina, with retinal defect, single,
which suggests a tentative code of 361.01. Now, as always, go to the Tabular List to
determine the accuracy of this code, and you will find 361.01 Recent detachment,
partial, with single defect. You have the correct code!

Code category 364 covers disorders of the iris and ciliary body. You are probably aware
that the iris is the colored area of your eye, located behind the cornea. You might not
know that the ciliary body refers to the muscles and tissues that are involved in
focusing the eye. The disorders of the iris and ciliary body include inflammations,
vascular disorders, degenerations, cysts and adhesions. Iridocyclitis is an
inflammation of the iris and ciliary body. Symptoms of this condition include eye
pain and redness, sensitivity to light, watering of the eye and decreased vision.
Iridoschisis is a condition in which the iris is split into two layers.

Sup erior obliq ue

O ptic chia sm

O ptic nerve Tro ch lea

R ec tus musc les:
Su perior
Med ial
Inferio r
Inferior oblique
La te ra l

Iris
Co rnea

Pup il

Prime Sclera
Primemovers
Moversof of
thethe
globe
Globe

0205502LB03A-25-13 25-25
Medical Coding and Billing Specialist

Glaucoma, included in code category 365, is a rise in intraocular pressure, which

restricts blood flow. In the Tabular List for this category, you will find descriptions
such as “open angle” and “angle closure.” Open angle means that the drainage
angle is open, but the outflow of aqueous humor, the watery substance that fills
the cavity between the lens and the cornea, is blocked. Angle closure, or closed
angle, means the iris closes the drainage angle and obstructs outflow of aqueous
humor. The most common condition is primary open-angle glaucoma. If the condition
is something other than this, the physician will document it.

We discussed cataracts earlier, in Lesson 24, as a manifestation of diabetes. A

variety of conditions that create a cloudy, or calcified, lens that obstructs vision
are known as cataracts. This obstruction can be partial or complete, in one eye
or both eyes, and in or on the lens. There are many kinds of cataracts, and they
are classified by their etiology (cause and time of occurrence), and then by their
morphology (size, shape, location). Open your ICD-9-CM manual to the Tabular
List to code category 366 Cataract. The first subcategory, 366.0 Infantile,
juvenile and presenile cataract, is classified as the etiology. The etiology
indicates the individual is younger than age 50 by categorizing infantile, juvenile
and presenile. The morphology further divides this subcategory. Subcategory 366.1
Senile cataract is the most common kind of cataract, affecting those persons older
than age 50. Cataracts in this group are of unknown cause, painless, and develop as
one ages. Cataracts that result from injury to the eye are known as traumatic, again
classified by etiology. In subcategory 366.4 you will find cataracts associated with
other diseases. In most cases, these cataracts are manifestations of another disease,
and you are instructed to code the underlying disease first. After-cataract is a
recurrent capsular cataract or any membrane in the pupillary area that occurs after
a procedure has been performed for extraction or absorption of the lens. You will
code this condition under category 366.5.

Category 367 includes codes for disorders of refraction and accommodation.

Refraction refers to the most common visual problem, refractive error. This
defect happens when the refracting media of the eye prevents light rays from
coming together into a single focus on the retina. This is due to an irregular cornea
curvature, problems with the focusing power of the lens, and the length of the
eye. This condition is known as farsightedness, nearsightedness and astigmatism.
Farsightedness, or hyperopia, initially causes difficulty in seeing objects
that are near and eventually affects distance vision.
Nearsightedness, or myopia, is when near objects can
be seen clearly while those in the distance appear blurred.
Astigmatism is a condition where a perfectly healthy eye
has a cornea that is not spherical. A minor degree of this
condition is normal and does not require glasses. More
severe conditions require special corrective glasses or
contact lenses that have no optical power, but rather,
correct the curvature. Accommodation is the process Severe conditions of astigmatism
by which the eye adjusts itself to focus on near objects. require special corrective glasses
or contact lenses.

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Eye strain, double vision, color blindness and night blindness are just a few of the visual
disturbances included in code category 368. Deutan defect is a disorder that affects
only males. This condition is characterized by difficulty distinguishing green and red
colors. To code this condition, locate the main term Defect in the Index to Diseases.
Locating the subterm deutan provides the tentative code of 368.52. Then turn to the
Tabular List to determine the highest level of specificity, and assign your chosen
code, 368.52 Color vision deficiencies, Deutan defect, as the correct one.

We will discuss categories 370 and 371 together because they both relate to the
cornea. Keratitis, code category 370, is an inflammation of the cornea. Corneal ulcers
and superficial inflammation with and without inflammation of the conjunctiva are
associated with keratitis. Corneal scars, deposits, edema and degenerations are some
of the disorders you will find in code category 371.

The most common disorder of the conjunctiva is conjunctivitis. Conjunctivitis

is an inflammation of the conjunctiva. The common symptoms of this acute
contagious disease are redness, discharge, itching and burning of the lids. A form
of conjunctivitis may be referred to as pink eye. A wedge-shaped conjunctival
thickening that advances from the inner corner of the eye toward the cornea is
termed pterygium. Other conditions in this code category consist of degeneration,
scars, vascular disorders and cysts.

Category 376 covers disorders of the orbit, which should not be confused with the globe.
Remember that the globe was also referred to as the eyeball. The orbit is the bone cavity
that contains the eyeball. Inflammation, protrusion, recession and deformity are some of
the disorders of the orbit. Enophthalmos is the term for recession of the eyeball deep
into the eye socket. This condition may be due to atrophy of the orbital tissue, trauma,
or surgery or the cause may be unspecified. To code enophthalmos resulting from
atrophy of the orbital tissue, you would locate the main term Enophthalmos in the Index
to Diseases. The subterms due to and atrophy of the orbital tissue provide 376.51 as the
tentative code. After you determine the highest level of specificity for the code in the
Tabular List, you should be confident that you’ve coded the condition correctly as 376.51
Enophthalmos due to atrophy of orbital tissue.

Diseases of the Ear and Mastoid Process (380-389)

This section contains codes for diseases and disorders of the external, middle and
inner ear; the mastoid process; vertiginous syndromes and other disorders of the
vestibular system; otosclerosis; and hearing loss. If applicable, you are to use an
additional external cause code to identify the cause of the ear condition. Note that
there are some INCLUDES , a few EXCLUDES and three manifestation codes that
direct you to code underlying diseases first.

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Medical Coding and Billing Specialist

Now let’s look at some of the terms you may encounter when you are dealing with
diseases of the ear and mastoid process.
 Otitis is an inflammation of the ear. The symptoms of otitis usually are pain,
fever, abnormalities of hearing, hearing loss, tinnitus (ringing, buzzing,
roaring or clicking noise in the ear) and vertigo (a form of dizziness).
 Externa refers to the external auditory canal. Otitis externa is an
inflammation of the external auditory canal.
 Media refers to the middle ear. Otitis media is an inflammation of the
middle ear.
 Suppurative means “to produce pus.” Acute nonsuppurative otitis
media is a brief, relatively severe inflammation of the middle ear without
the discharge of pus.
 Serous refers to a clear, watery fluid. Acute serous otitis media is a
brief, relatively severe inflammation with a collection of clear, watery
fluid in the middle ear.

Now that you are a little more comfortable with the terminology, let’s code a disorder
from category 380.

SUBJECTIVE
A 25-year-old female seeks assistance at an urgent care facility. She complains of
an inability to hear out of her left ear, and that her balance has been off x 1 day.
Patient denies cold or cough and is afebrile. She has no pain in the right ear.
OBJECTIVE
Using suction, the physician removes a large ball of wax under direct
visualization. No infection is noted. The ear canal is then irrigated.
ASSESSMENT
Ear wax.
PLAN
The patient is discharged in stable condition.

What is the problem? The problem isn’t that the patient has
an ear; rather, the wax is the problem. Turn in the Index to
Diseases to locate the main term Wax, and you will find Wax
in ear with code 380.4. Note this tentative code, and then
turn to the Tabular List to determine the highest level of
specificity. The code description of Impacted cerumen is
the medical term for wax in the ear, which is included under
that description. So you will assign code 380.4 Disorders of
external ear, Impacted cerumen for this scenario.

Impacted cerumen is
the medical term for
wax in the ear.
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The mastoid process is the nipple-like projection of the petrous part of the
temporal bone, that part which contains the structures of the internal ear. As you
know from your terminology, “itis” is an inflammation; therefore, mastoiditis is an
inflammation of any part of the mastoid process. This condition most often affects
children. Acute mastoiditis usually begins as a middle-ear infection (otitis media).
In severe cases of this disease, the mastoid air cells are fused together. Mastoid air
cells are numerous small, intercommunication cavities in the mastoid process.

The tympanic membrane constitutes the boundary between the external and
middle ear. This thin, tense membrane is also referred to as the drumhead,
drum, eardrum and tympanum. Disorders you will find in code category 384 are
inflammation and perforation of the eardrum.

Disorders of the ear often affect our balance. Code category 386 contains diseases and
conditions that include dizziness as a symptom. Open your manual to the Tabular
List, and note that this category EXCLUDES “vertigo NOS.” Meniere’s disease, for
instance, causes hearing and balance dysfunction. Symptoms of Meniere’s disease
include fluctuating deafness, ringing in ears and dizziness.

You will use code category 387 for otosclerosis, which is a pathological condition
of the bony part of the internal ear, called the bony labyrinth. Otosclerosis causes
formation of spongy bone, which may cause bony ankylosis, or a union of the bones
of a joint by proliferation (to grow and increase in number by means of reproduction)
of bone cells. This process can result in complete immobility of the bones and cause
progressive hearing impairment. Code 387 INCLUDES otospongiosis, as you will
note when you look at the code in the Tabular List.

You can find other disorders of the ear in code category 388. These disorders range
from degenerative disorders, to noise-induced hearing loss, to the basic earache.
Tinnitus is also located in this category. Tinnitus is defined as abnormal noises in
the ear, including ringing, clicking, roaring and buzzing.

Conditions included within code 389 for hearing loss range from conductive and
sensorineural hearing loss to deaf mutism. Conductive deafness is caused by a
defective sound-conducting apparatus of the external or middle ear. Turn to this
section in the Tabular List, and note that it is subdivided into the specific sites of the
ear. Sensorineural hearing loss, perceptive hearing loss or deafness, is caused by
a defect in nerve conduction.

Time for a breather! We’re now more than one-third of the way through the chapters
of the ICD-9-CM manual’s Tabular List! Are you surprised at how many significant
details there are relevant to such apparently small regions of the body as the eyes
and the ears? Of course, when you consider how complex the systems of sight and
sound are, all the parts, pieces and processes required for them to function properly
shouldn’t surprise you too much. Now, once again, complete the following Practice
Exercise to review some of the details you’ve just learned.

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 Step 10 Practice Exercise 25-3

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Malignant myopia
ICD-9-CM code: _______________________________

2. Macular degeneration, senile disciform

ICD-9-CM code: _______________________________

3. Pink eye
ICD-9-CM code: _______________________________

4. Orbital hemorrhage
ICD-9-CM code: _______________________________

5. Bullous myringitis
ICD-9-CM code: _______________________________

6. Meniere’s disease
ICD-9-CM code: _______________________________

7. ICD-9-CM Coding Challenge

PRESENTING PROBLEM
Protrusion of auricle.
A 3-year-old patient has a history of otitis media that has not responded to
multiple treatments of antibiotics. Review of recent CT reveals a fusion of
mastoid air cells.
PROCEDURE PERFORMED
COMPLETE MASTOIDECTOMY.
The mastoid cortex (a plate of bone on the lateral surface of the mastoid
process of the temporal bone) is removed. The fusion of mastoid air cells is
exposed. The infected mastoid air cells are removed by a curette and drill. A
temporary drain is placed, and the incision is sutured. The patient receives
IV antibiotics. No complications are noted.
POSTOPERATIVE DIAGNOSIS
Acute mastoiditis.

ICD-9-CM code: ___________________________________

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 Step 11 Review Practice Exercise 25-3

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 12 Diseases of the Circulatory System

(390-459), Part 1
 Chapter 7 of the Tabular List focuses on the circulatory system. This major body
system includes the heart and blood vessels. As you will learn, many diseases of
the heart are closely related. For example, one disease may be the cause of another,
or the diseases may occur in conjunction with each other. Because the circulatory
system includes so many diseases and related codes, we are once again dividing our
discussion into two major sections. In the first section, we discuss acute rheumatic
fever (codes 390 through 392), chronic rheumatic heart disease (codes 393 through
398), hypertensive disease (codes 401 through 405) and ischemic disease (codes 410
through 414). You will have several opportunities to practice coding some diagnoses
within these disease categories. So let’s get started!

Acute Rheumatic Fever (390-392)

Acute rheumatic fever is a febrile disease that occurs
mainly in children or young adults. Rheumatic fever usually
appears weeks after the person has experienced untreated or
inadequately treated strep throat or scarlet fever. Symptoms
of rheumatic fever include fever, joint pain, lesions of the
heart, abdominal pain, rash or nodules on the skin and chorea.
The heart lesions can eventually affect the heart valves and
the normal blood flow, which would lead to disease diagnoses
in the subsequent section of the Tabular List, which focuses
on rheumatic heart disease. Because of this relationship,
rheumatic fever can be categorized “without mention of heart
involvement,” “with heart involvement” or as “Rheumatic
chorea.” Turn to the Tabular List to find more information
about coding this condition. Rheumatic fever with mention
of heart involvement EXCLUDES any diagnosis that indicates Acute rheumatic
chronic heart diseases of rheumatic origin unless rheumatic fever is a febrile
fever is also present or there is evidence of recrudescence or disease that occurs
activity of the rheumatic process. Chorea is the occurrence of mainly in children or
irregular, spasmodic, involuntary movements of the limbs or facial young adults.
muscles. In this section, chorea is linked with rheumatic fever and
streptococcal infections. The Tabular List for the rheumatic chorea
code EXCLUDES Huntington’s chorea.

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Let’s get right into some coding practice related to rheumatic fever to see how well you
understand this section of the Tabular List. See how accurately and quickly you can code
this description: A patient is diagnosed with acute rheumatic fever with myocarditis.

To accurately code this scenario, would you begin with fever or myocarditis as your main
term? One coding pathway is more direct, but let’s take a look at both options. First,
turn to the Index to Diseases and locate the main term Myocarditis. The subterm
rheumatic provides us with code 398.0, but look further, to the phrase “active or acute.”
You know the condition is acute, so your tentative code would be 391.2. This is not
a particularly straightforward coding pathway, so let’s try the other option. Use the
coding pathway of Fever, rheumatic, with heart involvement, myocarditis to locate the
tentative code 391.2. Now you will need to determine the highest level of specificity
using the Tabular List. Based on the information you find there, you can confidently
assign 391.2 Rheumatic fever with heart involvement, Acute rheumatic
myocarditis for the given diagnosis of acute rheumatic fever with myocarditis.

Chronic Rheumatic Heart Disease (393-398)

As we mentioned previously, rheumatic heart disease is the condition that develops
when the heart valves are damaged by rheumatic fever. This resulting condition may
be a life-long disease. To avoid contracting rheumatic heart disease, one must prevent
rheumatic fever from ever occurring. In this section, you will find abnormalities of
the heart valves, such as stenosis, insufficiency and other valve diseases. Stenosis is
a narrowing, or stricture, of the valve. Insufficiency indicates a malfunction and/or
narrowing of the valve. The narrowing and malfunction of the various valves restrict
the heart’s normal blood flow. These valves are flaps, or cusps, within the heart. Codes
for the mitral valve, the aortic valve and a combination of the mitral and aortic valves
are subdivided into categories 394, 395 and 396. Tricuspid, pulmonary and unspecified
valves are included within the 397 code category. As you look through this portion
of the Tabular List, you will note that in several subcategories the designated code
EXCLUDES diseases that are not specified as rheumatic.

Aorta:
Arch
Superior vena cava Descending
Ascending
Pulmonary a. Pulmonary a.
Pulmonary v. Pulmonary v.
Pulmonic valve Interatrial septum
Right atrium Left atrium
Tricuspid valve Bicuspid valve
Chordae tendine a e
Right ventricle
Aortic valve
Interventricular septum
Left ventricle
Inferior vena cava

Internal cardiac
Internal Cardiacanatomy
Anatomyand
andcirculation
Circulationflow
Flow

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The bicuspid, or more commonly called, mitral valve is located between the left
atrium and the left ventrical of the heart. The aortic valve is positioned between
the left ventricle and the ascending aorta. The tricuspid valve is located between
the right atrium and right ventricle. The pulmonary valve lies at the entrance to
the pulmonary trunk, coming from the right ventricle.

Okay—let’s code the following scenario associated with what you’ve just read about
chronic rheumatic heart disease.

SUBJECTIVE
A 47-year-old male is admitted to the emergency department. He has been
feeling fatigued and has had a cough and swollen feet, for the past week.
Two hours prior to admission, he was awakened by difficulty breathing and
chest tightness.
OBJECTIVE
Blood pressure is normal. Patient is afebrile. HEENT normal. Cardiovascular
exam notes rumbling apical diastolic murmur with presystolic accentuation.
Crackles heard on respiratory exam. Feet are swollen. Chest x-ray,
echocardiogram, and ECG are ordered. Chest x-ray shows signs of
pulmonary edema.
ASSESSMENT
Patient suffers from mitral stenosis.
PLAN
He will be admitted by his PCP for additional work-up.

To code this scenario, you will need to determine the coding pathway to follow in the
Index to Diseases. Is the problem that the patient has a mitral valve? No, the problem
is the stenosis, or narrowing, of that valve. So begin with the main term Stenosis in
the Index to Diseases. Once you’ve located this term, find the subterm mitral, and you
have the tentative code 394.0. But, as you know, you aren’t done until you turn to the
Tabular List to determine the highest level of specificity. In the Tabular List, code
394.0 has no inclusions, exclusions or additional notes, so you can confidently assign
394.0 Diseases of the mitral valve, Mitral stenosis, for this condition.

Hypertensive Disease (401-405)

Hypertension refers to high blood pressure. The
diagnosis of hypertension is confirmed in adults
when the average of two or more blood pressure
measurements on at least two visits reveal a
diastolic (bottom number) pressure of 90 mmHg
or higher or a systolic (top number) pressure of 140
mmHg or higher.

Hypertension refers to
high blood pressure.
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Medical Coding and Billing Specialist

Benign hypertension refers to a relatively mild degree of hypertension of prolonged

or chronic duration. Malignant hypertension is an accelerated, severe hypertensive
disorder, with progressive vascular damage and a poor prognosis. A diagnosis of
hypertension without further qualification is classified as unspecified.

The Index to Diseases includes a table under the main term Hypertension with subterms
indexed in the usual way. The three columns included in this table provide codes for
Malignant, Benign and Unspecified. If the conditions are specified by the dictation you
receive, you might code many conditions in combination with hypertension.

Hypertensive Heart Disease—Certain heart conditions are assigned to code

group 402 Hypertensive heart disease when a causal relationship is stated due to
hypertension. Note that the 402 group of codes includes heart failure. If heart failure
is stated in the dictation, an additional code is required to identify the type of heart
failure. When a heart condition and hypertension are documented but are not linked
as causal relationships, code the two conditions separately.

Hypertension and Chronic Kidney Disease—The ICD-9-CM presumes a

cause-and-effect relationship between hypertension and chronic kidney disease, so
you should code these combined diagnoses to group 403 Hypertensive chronic
kidney disease, when classified as renal failure with hypertension.

Hypertensive Heart and Chronic Kidney Disease—When a heart condition

and a kidney condition both exist, assign a combination code from code group 404
Hypertensive heart and chronic kidney disease. Fifth digits are provided to
indicate whether congestive heart failure, renal failure or both are present. For this
category, use an additional code to specify the type of heart failure.

Essential hypertension, also known as primary hypertension, is the state

of having elevated blood pressure with no apparent cause. Modern drugs and
appropriate changes in diet and lifestyle are often successful as treatment for this
condition. When elevated blood pressure is documented, be careful not to assume
that hypertension is the correct diagnosis. Another specific code exists for elevated
blood pressure, and it’s not in this section.

Hypertensive heart disease is the description used for any condition due to
hypertension classifiable to codes 429.0 through 429.3, 429.8 and 429.9. You
are directed to use an additional code to specify the type of heart failure if it
is documented. When the causal relationship between hypertension and heart
disease is not documented, code each condition separately.

So let’s code for hypertensive cardiovascular disease with CHF (congestive heart failure).
Based on what we just said, this condition requires two codes for accurate coding. Locate
the Hypertension table in the Index to Diseases. You will quickly find Hypertension
because it is the main term in the Hypertension table, and applies to all subterms
in that table. So the coding pathway is hypertension, cardiovascular disease, with,
heart failure. Malignant or benign is not documented, so you move to the Unspecified
column of the Hypertension table.

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Then turn to the Tabular List to determine the highest level of specificity for the
tentative code 402.91. Although this does seem to be the correct code, you aren’t
done coding just yet! Remember that you need to use an additional code to specify
the type of heart failure. So now locate Failure as the main term in the Index to
Diseases. The subterm congestive provides the tentative code of 428.0 and directs
you to “see also Failure, heart.” The coding pathway Failure, heart, congestive
provides the same tentative code. Once again, turn to the Tabular List to determine
the highest level of specificity. You can now assign codes 402.91 Hypertensive
heart disease Unspecified, With heart failure and 428.0 Congestive heart
failure, unspecified for accurate coding of this condition.

Terminology: Nephros is Greek for kidney while

the Latin term for kidney is renal.

The ICD-9-CM presumes a cause-and-effect relationship between hypertension

and kidney disease, so you should code these combined diagnoses to group 403
Hypertensive chronic kidney disease. Turn to the Tabular List to review the
fifth-digit subclassification box for hypertensive kidney disease.

When a heart condition and a kidney condition both exist, you will assign a combination
code from code group 404 Hypertensive heart and chronic kidney disease. You
will presume a relationship between the hypertension and renal failure, whether the
relationship is documented or not. The relationship between hypertension and heart and
chronic kidney disease is discussed in Diagnostic Coding and Reporting Guidelines for
Outpatient Services in the front of the ICD-9-CM manual. If in doubt ask the physician
so that you will assign accurate diagnostic codes for this hypertension category.

Let’s code malignant hypertensive cardiovascular renal disease for practice. Once again,
turn to the Hypertension table in the Index to Diseases. Then locate the subterm
cardiovascular renal in the table. The Malignant column provides the tentative code
of 404.00. You will determine the highest level of specificity in the Tabular List, and
based on the information you find there, assign 404.00 Hypertensive heart and
chronic kidney disease, Malignant, without heart failure and with chronic
kidney disease stage I through stage IV, or unspecified as the accurate code.
However, the notes found with the fifth-digit subclassification instruct you to use an
additional code to identify the state of the chronic kidney disease. Return to the Index
and locate the coding pathway Disease, kidney, chronic. Code 585.9 is provided as the
tentative code. A quick check with the Tabular List verifies 585.9 Chronic kidney
disease, unspecified is correct because the stage is not documented.

Secondary hypertension affects about 10 percent of all cases of hypertension.

Unlike essential hypertension, this condition has an identifiable cause. Secondary
hypertension is due to or associated with a variety of primary diseases, such as renal
disorders, disorders of the central nervous system, endocrine diseases and vascular
diseases. When you code secondary hypertension, two codes are necessary to identify
the underlying disease and the hypertension.

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Ischemic Heart Disease (410-414)

Any of a group of acute or chronic cardiac disabilities resulting from insufficient supply
of oxygenated blood to the heart is known as ischemic heart disease. This section
includes conditions such as myocardial infarction, angina pectoris and aneurysms.
Myocardial infarction (MI) is a sudden insufficiency of blood supply to an area of the
heart muscle, usually as the result of a coronary artery occlusion. In the ICD-9-CM
manual, the area of the heart muscle is subdivided into anatomical sites at which the
MI might occur. Diagnostic statements do not always mention the affected wall, but
you can usually find this information in the EKG report. If that report is not available,
you will code to “Unspecified site.” Turn to the Tabular List to review the fifth-digit
subclassifications provided for the myocardial infarction category 410. Select the fifth
digit to indicate that the current infarction is unspecified, the initial episode of care, or
a subsequent episode of care for the same infarction. Patients sometimes experience
a second infarction that involves another wall. In that case, you would code for both
infarctions according to the site involved, and you would assign a fifth-digit 1 to
indicate an initial episode of care for each infarction.
Myocardial infarctions are also a challenge to code. To help you understand the
coding hierarchy for MIs, here is a summary of the codes you would use:
1. 410 Acute myocardial infarction—Use this classification if the
documented duration of the MI is eight weeks or less.
2. 414.8 Other specified forms of chronic ischemic heart disease—
Use this classification after the acute period has expired.
3. 412 Old myocardial infarction—Use this category for “old,” healed
MIs that show no symptoms.
The eight-week rule for coding MIs, combined with the fifth digits for code 410,
can cause diagnosis difficulties for both you as the coder and the insurance payer.
According to ICD-9-CM rules, you use the acute diagnosis throughout the entire
eight-week phase of treatment. If the patient is dismissed from the hospital,
and then readmitted with a new MI during the eight-week time period, you will
assign the fifth-digit 1, which indicates an initial episode of care. However, if the
second admission is related to the previous admission and not to a new MI, it is a
subsequent episode of care, and you would assign the fifth-digit 2. Look again in
the Tabular List at code 410. Do you see the box that says “The following fifth-digit
subclassification is for use with category 410:”? This gives you the information you
need to assign the fifth digit correctly!
Here’s another scenario for you to review, and demonstrate your increasing coding
skills pertaining to heart disease. When you’ve completed your assessment and
identified the code or codes you would assign to the diagnosis, compare your steps to
the summary that follows the scenario to see how well they match.

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CHIEF COMPLAINT
Chest pain.
HISTORY OF PRESENT ILLNESS
The patient is a white male who presents with a chief complaint of “chest pain.” The patient
has a prior history of coronary artery disease. The patient presents today stating that his chest
pain started yesterday evening and has been somewhat intermittent. The severity of the pain
has progressively increased. He describes the pain as a sharp and heavy pain which radiates
to his neck and left arm. He ranks the pain a 7 on a scale of 1-10. He admits some shortness
of breath and diaphoresis. He states that he has had nausea and 3 episodes of vomiting
tonight. He denies any fever or chills. He admits prior episodes of similar pain prior to his
PTCA in 19XX. He states the pain is somewhat worse with walking and seems to be relieved
with rest. There is no change in pain with positioning. He states that he took 3 nitroglycerin
tablets sublingually over the past 1 hour, which he states has partially relieved his pain. The
patient ranks his present pain a 4 on a scale of 1-10. The most recent episode of pain has
lasted 1 hour. The patient denies any history of recent surgery, head trauma, recent stroke,
abnormal bleeding such as blood in urine or stool or nosebleed.
PAST MEDICAL HISTORY
Hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 19XX.
Medications: Aspirin 81 mg daily. Humulin N insulin 50 units in a.m. HCTZ 50 mg daily.
Nitroglycerin 1/150 sublingually p.r.n. chest pain.
ALLERGIES: PENICILLIN.
Social history: Denies alcohol or drugs. Smokes 2 packs of cigarettes per day. Works as a banker.
Family history: Positive for coronary artery disease (father and brother).
REVIEW OF SYSTEMS
All other systems reviewed and are negative.
PHYSICAL EXAMINATION
GENERAL: The patient is a 40-year-old white male. The patient is moderately obese, but he is
otherwise well developed and well nourished. He appears in moderate discomfort, but there is
no evidence of distress. He is alert and oriented to person, place and circumstance. There is no
evidence of respiratory distress. The patient ambulates without gait abnormality or difficulty.
HEENT: Normocephalic, atraumatic head. Pupils are 2.5 mm, equal, round and react to
light bilaterally. Extraocular muscles are intact bilaterally. External auditory canals are clear
bilaterally. Tympanic membranes are clear and intact bilaterally.
NECK: No JVD. Neck is supple. There is free range of motion and no tenderness, thyromegaly
or lymphadenopathy noted. Pharynx: Clear, no erythema, exudates or tonsillar enlargement.
CHEST: No chest wall tenderness to palpation. Heart: Irregularly irregular rate and rhythm,
no murmurs, gallops or rubs. Normal PMI. Lungs: Clear to auscultation bilaterally.
ABDOMEN: Soft, nondistended. No tenderness noted. No CVAT.
SKIN: Warm, diaphoretic, mucous membranes moist, normal turgor, no rash noted.
EXTREMITIES: No gross visible deformity, free range of motion. No edema or cyanosis. No
calf or thigh tenderness or swelling.
COURSE IN EMERGENCY DEPARTMENT
The patient’s chest pain improved after the sublingual nitroglycerin and completely resolved
with the nitroglycerin drip at 30 ug/min. He tolerated the TPA well. He was transferred to the
CCU in a stable condition.
IMPRESSION
Acute inferior myocardial infarction.

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Medical Coding and Billing Specialist

How did you do? Let’s compare notes. Begin by locating the main term Infarction
in the Index to Diseases, and then the subterms myocardial, inferior. This coding
pathway provides the tentative code of 410.4  . Determine the highest level of
specificity in the Tabular List. Note that code 410.4 is for an Acute myocardial
infarction, Of other wall inferior. The shaded box under code 410 indicates that
a fifth-digit subclassification is required for accurate coding of this disease. And so
you use 1 as the fifth digit because the initial episode is documented, and you assign
410.41 for this scenario.

This is a lot of information to take in! Let’s pause here and do a quick review. If there
are sections you’re struggling with, be sure to contact your instructor for assistance.

 Step 13 Practice Exercise 25-4

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Rheumatic chorea
ICD-9-CM code: _______________________________

2. Rheumatic endocarditis
ICD-9-CM code: _______________________________

3. Benign essential hypertension

ICD-9-CM code: _______________________________

4. Secondary hypertension due to Cushing’s disease

ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

5. Acute anterolateral myocardial infarction, initial episode

ICD-9-CM code: _______________________________

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6. ICD-9-CM Coding Challenge

PREOPERATIVE DIAGNOSIS
Chronic renal failure with hypertension, with need for dialysis access due to
end-stage renal disease.
POSTOPERATIVE DIAGNOSIS
Same.
PROCEDURE PERFORMED
PLACEMENT OF ARTERIOVENOUS FISTULA.
After informed consent, this 25-year-old female was brought to the operating room
and placed in a supine position on the table. After induction of anesthesia, the patient
was prepped and draped appropriately. I identified the cephalic vein, marked it
and the radial artery. An area was marked between these two, and the area was
infiltrated with Marcaine and epinephrine prior to making the incision. I dissected
out the cephalic vein first, followed by the radial artery. The distal end of the vein was
clamped and transected. I then occluded the radial artery and both ends. Bleeding was
controlled appropriately with clamps.
I then performed an end-to-end anastomosis with Gore-Tex sutures. Prior to
completing the anastomosis, the fistula was flushed with heparinized saline. The
procedure was completed with the final sutures, and the fistula was opened to
evaluate the flow in the vessel. Good thrill (vibration) and bruit (harsh or musical
sound) were present over the entire area. The subcutaneous tissue and skin were
closed appropriately, and sterile dressings were applied. The fistula will be evaluated
in the next 24 hours for dialysis use.
ICD-9-CM code: _________________
ICD-9-CM code: _________________

 Step 14 Review Practice Exercise 25-4

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

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Medical Coding and Billing Specialist

 Step 15 Diseases of the Circulatory System

(390-459), Part 2
 In this second part of our discussion about Chapter 7 of the Tabular List, you will
learn about how to code diseases of pulmonary circulation (codes 415 through 417);
other forms of heart disease (codes 420-429); cerebrovascular disease (codes 430
through 438); diseases of the arteries, arterioles and capillaries (codes 440 through
449); diseases of the veins and lymphatics and other diseases of the circulatory
system (codes 451 through 459).

This lesson is loaded with coding information and details, so if you are feeling at all
overwhelmed at this point, stop for a few minutes and reflect on how much you have
already learned, and consider how familiar many of the details from this and the
previous lessons about ICD-9-CM coding have already become. You’re doing great!
So take a few slow, deep breaths, and let’s continue the journey over some new
coding pathways.

Diseases of Pulmonary Circulation (415-417)

Diseases of pulmonary circulation include acute pulmonary heart disease, chronic
pulmonary heart disease and other diseases of the pulmonary circulation. A
pulmonary embolism is the closure of the pulmonary artery or branch as the
result of a blood clot. Infarction is necrosis of lung tissue as the result of an
obstruction of the arterial blood supply. The infarction is usually the result of an
embolism. Primary pulmonary hypertension is a rare disease characterized by
an increase in pulmonary circulation with no apparent cause.

Take a look at the Tabular List for this range of codes, and search for inclusions,
exclusions and notes to assist you with accurate coding. For example, notice that
code 415.0 EXCLUDES “cor pulmonale NOS;” you are directed to use code 416.9
instead. Code 415.1 EXCLUDES pulmonary embolisms and infarctions that are
complications of abortion (codes 634 through 638 with a fourth digit of .6 and
code 639.6); ectopic or molar pregnancy (code 639.6); pregnancy, childbirth or
the puerperium (codes 673.0 through 673.8); and personal history of pulmonary
embolism (code V12.55). Also note that codes within category 417 EXCLUDES
“congenital arteriovenous fistula, congenital aneurysm and congenital arteriovenous
aneurysm” and alternative codes are included for use with these conditions.

Other Forms of Heart Disease (420-429)

This section includes codes for inflammations, disorders and failures of the heart.
Although this group of codes is quite large, you should find that coding these
conditions is fairly straightforward. And, as always, if you have questions about
anything in this or any other section, call your instructor. Remember, we want you
to succeed, and someone will be available to answer your questions!

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 ICD-9-CM Coding—From Mental Disorders to Circulatory System

Cerebrovascular Disease (430-438)

Cerebrovascular diseases (CVDs) belong to a group of conditions that relate to any
disease affecting an artery supplying blood to the brain. Intracranial hemorrhage,
occlusions, transient cerebral ischemia and late effects of cerebrovascular disease
are some conditions you will find in this section. This group of codes INCLUDES
conditions that are a result of hypertension. You will need to use an additional code
for those conditions to identify the presence of hypertension.

Ruptured blood vessels in the brain result in intracranial hemorrhages. There

are four basic types of intracranial hemorrhage, classified according to where the
hemorrhage occurs: subarachnoid (430), intracerebral (431), extradural (432.0)
and subdural (432.1). To locate the ICD-9-CM code for each of these conditions, use
the main term Hemorrhage, and then the type of hemorrhage as the subterm. This
type of hemorrhage is nontraumatic, or not caused by trauma.

Subarachnoid hemorrhages, code category 430, are located on the surface of

the brain. Another source of subarachnoid hemorrhages is ruptured congenital
aneurysms located along the middle or anterior cerebral arteries or the
communicating branches, known as the Circle of Willis. These small aneurysms
are known as berry aneurysms, and they are frequently lethal if they are not
recognized and treated with surgery.

F roFrontal
ntal l o be
lobe Circle
Ci rcl eofoWillis:
f Wi ll is :
Anterior
Anteriocerebral
r cereba.
ral a
InterMiddle
nal cacerebral
roti d aa.
.
A nterior
Anterior
TTemporal
emporalobe l l o be communicating
c ommuni cati n a.g a.
peSuperior
ri or cercerebellar
ebel lar aa. . Mi ddl e cerebral a.
Internal carotid a.
Pons
Pons P os teri or
Posterior
AnAnterior
teri or i ninferior
feri or communicating
c ommuni cati n a.g a.
cecerebellar
rebell ar a a.. Posterior
P os teri ocerebral
r cereba. ral a
Anterior spinal a.
a. Basilar
Bas il aa.
r a.
Anterior spinal
CerCerebellum
e b el l um Vertebraa.l a.
Vertebral

Intracranial arterial systemic circulation

Intracerebral hemorrhage is bleeding within the brain caused by ruptured blood

vessels in the head. It is one of the three main mechanisms by which a stroke can
occur. The blood can irritate the brain tissue, causing swelling, or it can collect in
a mass, referred to as a hematoma. Either of these conditions can cause pressure
on the brain tissues and can rapidly destroy them. Intracerebral hemorrhages
are confirmed by a CT or MRI; treatment may range from medication to surgical
removal of the hematoma.

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Medical Coding and Billing Specialist

Extradural hemorrhages (also known as epidural hemorrhages) are located

in the space between the skull and the dura, or brain lining. These hemorrhages
tend to form slowly over a period of several hours. Because they form so slowly, the
hemorrhages can often be drained before they cause serious consequences. If they
are left untreated, epidural hemorrhages are fatal.

Bleeding between the outer covering of the brain (dura) and the brain’s surface is
referred to as subdural hemorrhage.

Three-dimensional detail of meninges

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 ICD-9-CM Coding—From Mental Disorders to Circulatory System

Here’s another sample to code. You’ll probably have this one figured out as quickly
as you can locate the codes in your manual.

PREOPERATIVE DIAGNOSIS
A 76-year-old male complains of headache, weakness, slurred speech
and lethargy. Patient does not recall hitting his head. CT confirms
subdural hemorrhage.
PROCEDURE PERFORMED
CRANIOTOMY.
An incision is made in the scalp, and the scalp is peeled away. A bur drill is
used to drill into the skull to access the hematoma. The dura mater is then
incised to reach the hemorrhage under the dura mater. The hematoma is
decompressed, and the bleeding is controlled. The dura is sutured closed,
followed by repositioning and suturing of the scalp.
POSTOPERATIVE DIAGNOSIS
Subdural hemorrhage.

The correct code can be determined fairly easily on this one. Go to the Index to
Diseases using the coding pathway of main term Hemorrhage and subterm subdural.
You should note a tentative code of 432.1. Then go to the Tabular List to determine
highest level of specificity. As you probably already know, the accurate code to
assign is 432.1 Subdural hemorrhage. Great job!

The next two categories in the “Cerebrovascular Disease (430-438)” section deal with
occlusions, a term that refers to the act of closing, or the state of being closed. An
obstruction of the cerebral or precerebral arteries can result in a cerebral infarction.
You will note the fifth-digit subclassification box in the Tabular List for categories
433 and 434. Use of the fifth digit here indicates whether or not a cerebral infarction
was mentioned. Categories 433 and 434 also instruct you to use an additional code,
if applicable, to identify status post administration of tPA (rtPA) in a different
facility within the last 24 hours prior to admission to current facility, noting V45.88
is the correct code to apply. The drugs tPA (tissue plasminogen activator) and rtPA
(recombinant tissue plasminogen activator) are given within three hours of a stroke,
after which its detriments may outweigh its benefits of breaking down blood clots.

The last code category we will discuss in this section is that for late effects of
cerebrovascular disease, 438. Do you remember learning about late effects? A late
effect is the residual condition produced after the acute phase of an illness or injury
has terminated. If a residual condition is documented with the late effect, you will
code that condition first, and then the late effect. Turn to code group 438 in your
manual and be sure to read the notes associated with it, as well as all the various
subcategories and the EXCLUDES associated with code 438.5.

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Diseases of Arteries, Arterioles, and Capillaries (440-449)

This section contains diagnosis
codes for atherosclerosis,
aortic aneurysms, embolisms,
thrombosis and a variety of
other diseases that pertain
to the blood vessels. An
aneurysm is a sac formed
by the dilation of the wall of
an artery, vein or the heart.
The sac is filled with fluid or
clotted blood, often forming a
pulsating tumor. When this
sac is formed at the site of
the aorta, it is termed aortic
aneurysm. An embolism is
when an artery is suddenly
blocked by a clot or foreign
material. Thrombosis is the
formation, development or presence of a thrombus, or an aggregation of blood factors.
These blood factors are primarily platelets and protein with entrapment of cellular
elements. There are many INCLUDES and EXCLUDES listed in these code groups, so
be sure to read the details closely when you code from this section.

Atherosclerosis is a common disorder of the arteries. This condition is set in motion

when cells that line the arteries are damaged. Plaque develops at the site of the
damage. These deposits impede or eventually shut off the blood flow. This condition
can be specified to the aorta, the renal artery or the extremities. Atherosclerosis of the
extremities is more common in the legs than in the arms. When a person with this
condition runs or walks a long way, the blood supply is inadequate, which results in
cramping of the legs. Atherosclerosis can be prevented with a low-fat, low-cholesterol
and low-salt diet.

Now let’s try your skills coding for an aneurysm of the subclavian artery. To begin,
locate the main term Aneurysm in the Index to Diseases. Locating the subterm
subclavian provides the tentative code of 442.82. Turn to the Tabular List to
determine the highest level of specificity. You can easily and confidently assign 442.82
Other aneurysm, Subclavian artery as the correct code.

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Diseases of Veins and Lymphatics, and Other Diseases

of the Circulatory System (451-459)
In this section of Chapter 7, you will see conditions that pertain to the veins and
lymph channels, hypotension and other disorders of the circulatory system. Code
categories 451 through 456 cover inflammation, obstruction, dilation and distention of
veins. Hemorrhoids are an example of a varicose condition of external hemorrhoidal
veins and can be found in code category 455. The Tabular List provides inclusions
and exclusions to assist you with your diagnostic coding of these conditions. Category
451 also notes to use an additional E code to identify the drug if the condition is drug
induced.

Note in the Tabular List that the conditions of the lymph channels in code group
457 are specifically for noninfectious disorders. It’s also important to know that
lymphedema may or may not be due to a mastectomy but that it is caused by a
reduction in the lymphatic circulation. Lymphangitis is an inflammation of the
lymph vessel.

The condition of abnormally low blood pressure is known as hypotension. This

condition is covered in the code group 458. Orthostatic or postural hypotension
refers to a drop in the blood pressure when there is a sudden change in body
position. Hypotension caused by medication is referred to as iatrogenic
hypotension.

 Step 16 Practice Exercise 25-5

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Idiopathic pulmonary hypertension

ICD-9-CM code: _______________________________

2. Wenckebach’s phenomenon
ICD-9-CM code: _______________________________

3. Arteriolosclerosis of the extremities

ICD-9-CM code: _______________________________

4. Varicose veins of the lower extremity

ICD-9-CM code: _______________________________

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5. ICD-9-CM Coding Challenge

PREOPERATIVE DIAGNOSIS
Sick sinus syndrome.

POSTOPERATIVE DIAGNOSIS
Sick sinus syndrome.

PROCEDURE PERFORMED
DUAL CHAMBER PACEMAKER AND ATRIAL AND VENTRICULAR LEADS.

INDICATIONS FOR PROCEDURE

This patient has been experiencing increasing episodes of sick sinus syndrome
which are not able to be controlled with medication. A dual-chamber pacemaker
was recommended after discussion with the patient and his family. This
gentleman and his family were informed of all potential complications, including
infection, hematoma, pneumothorax, hemothorax, myocardial infarction, and
possibly death. The patient has agreed to the procedure and signed the consent.

PROCEDURE
The patient was admitted to the cardiac catheterization lab and placed on the
table. He was prepped and draped in the usual manner. Adequate anesthesia
was achieved, and the procedure was started. The pacemaker pocket was
created with hemostasis. The pocket was placed in the left infraclavicular area.
A 9 French peel-away sheath was used to introduce an atrial and a ventricular
lead into their correct position. The leads were sutured and secured.

The pulse generator was then connected to the leads. The pocket was prepared
for insertion of the generator. The pacemaker and leads were placed in the
pocket, and the pocket was closed in 2 layers.

The patient tolerated the procedure well and was discharged to the
postanesthesia care unit.

ICD-9-CM code: ____________________________________

 Step 17 Review Practice Exercise 25-5

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

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 Step 18 Lesson Summary

 Hurray! You’ve completed all the new information in this lesson. You should be
feeling really proud of your progress toward becoming a medical coding and billing
specialist! You’ve made it through an introduction to Chapters 5 through 7 of
the ICD-9-CM manual’s Tabular List, and you’ve learned a lot of valuable coding
information in the process.

Do you know how it feels to be training for some challenging physical event? Maybe
even for a marathon? If you do, you might recognize some things in common between
doing that and working your way through these lessons. There are periods of
intensity when you wonder whether you’re going to reach the smaller goals you set
for yourself along the way to the finish line. Each time you do, you are inspired and
feel even more energy for the next step. You are in the final lap of this lesson and
well on your way toward your goal of consistently using ICD-9-CM codes correctly!

To finish this part of your training to become a medical coding and billing specialist,
take whatever time you need to go back and review anything in this lesson that you
still have questions about, or any coding exercises that you’re not totally comfortable
with. If anything still confuses you, remember that you can call your instructor and
ask for help. When you’re ready, go ahead and take the quiz. Then take a few more
deep breaths, clear your head and you’ll be ready to start fresh with the next lesson.

 Step 19 Mail-in Quiz 25

 Follow the steps to complete the Quiz.

a. Be sure you’ve mastered the instruction and the Practice Exercises that
this Quiz covers.
b. Mark your answers on your Quiz. Remember to check your answers with the
lesson content.
c. When you’ve finished, transfer your answers to the Answer Sheet. Use only
blue or black ink.
d. Important! Please fill in all information requested on your Answer Sheet or
when submitting your Quiz via e-mail.
e. Submit your answers to the school via mail, fax or, to receive your grade
immediately, submit your answers online at www.uscareerinstitute.edu.

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Medical Coding and Billing Specialist

Mail-in Quiz 25
Choose the best answer from the choices provided. Each item is worth 2 points.

1. Which is true of the diagnosis hypertensive chronic kidney disease? _____

a. You should code hypertension as the primary diagnosis and chronic
kidney disease as a coexisting diagnosis.
b. You should code one combined diagnosis because there is a
cause-and-effect relationship between hypertension and
chronic kidney disease.
c. You should only code the chronic kidney disease.
d. You should code hypertensive heart disease with chronic
kidney disease.

2. The central nervous system is composed of the _____.

a. brain and nerves
b. brain and spinal cord
c. ganglia and nerves
d. nerves and spinal cord

3. _____ is the closure of the pulmonary artery or branch as the result of a

blood clot.
a. An infarction
b. Primary pulmonary hypertension
c. A pulmonary embolism
d. Secondary hypertension

4. Which is a true statement of shared psychotic disorder? _____

a. It is a mental disorder two people share.
b. It is sharing patient files with other physicians.
c. The first person with the delusional disorder convinces the second person
to accept the delusions.
d. Both a and c

5. Cataracts are classified by _____.

a. their size and location
b. cause and time of occurence
c. time of occurrence and their location
d. etiology and their morphology

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6. Which statement is true about the term intractable? _____

a. This term is found in the fifth-digit subclassification for category 345.
b. Intractable indicates the patient is responding to current medications for
the disease.
c. Intractable can be coded for 346 Migraine even if it is not documented.
d. You can guess by the medications for migraines if you should use this code.

7. _____ is a disease made famous when baseball player Lou Gehrig

contracted it.
a. Amyotrophic lateral sclerosis
b. ALS
c. Lou Gehrig’s disease
d. All of the above

8. Which is not a true statement of secondary hypertension? _____

a. Two codes are necessary to identify the underlying disease and
the hypertension.
b. It affects about 90 percent of all cases.
c. This condition has an identifiable cause.
d. This condition is due to or associated with a variety of primary diseases.

9. Which statement is not true of category 295? _____

a. It INCLUDES schizophrenia of the types described in codes 295.0
through 295.9 that occur in children.
b. The category EXCLUDES childhood type schizophrenia (299.9).
c. Category 295 requires a fifth-digit subclassification to describe the
current condition of the disorder.
d. The category INCLUDES infantile autism.

10. Rheumatic heart disease is the condition that develops when the
heart valves are damaged by rheumatic fever. Which heart valves are
specified within the 397 code category? _____
a. A combination of the mitral and aortic valves
b. Mitral valve
c. Tricuspid, pulmonary and unspecified valves
d. Mitral, tricuspid and pulmonary valves

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Medical Coding and Billing Specialist

11. Which is not a true statement of iridocyclitis? _____

a. It is an inflammation of the iris and ciliary body.
b. It is a condition in which the iris is split into two layers.
c. Symptoms of this condition include eye pain and redness, sensitivity to
light, watering of the eye and decreased vision.
d. None of the above

12. Which statement is not true of an extradural hemorrhage? _____

a. It forms very quickly.
b. It is also known as an epidural hemorrhage.
c. If left untreated, it is fatal.
d. It is located in the space between the skull and the dura.

13. Categories 303, 304 and 305 require a fifth-digit subclassification

consisting of the following: _____ and in remission.
a. Specified type, continuous, epic
b. Unspecified, continuous, epic
c. Unspecified, continuous, episodic
d. Specified type, continuous, episodic

14. Which is not a true statement? _____

a. Otitis is an inflammation of the ear.
b. Media refers to the external auditory canal.
c. Otitis externa is an inflammation of the external auditory canal.
d. Otitis media is an inflammation of the middle ear.

15. Which statement is not true about multiple sclerosis? _____

a. This disease involves both sensory and motor abnormalities.
b. Symptoms involving the senses include blurred vision, a loss of the
feeling of touch and unusual tingling sensations.
c. MS affects men about twice as often as it does women.
d. Currently MS can be treated with interferon drugs, which help reduce
the frequency of symptoms.

16. What are the two types of background retinopathy? _____

a. One is a detachment and one is not.
b. One is noninflammatory and one is inflammatory.
c. One is designated as a manifestation from diabetes and one is not.
d. None of the above

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17. The four basic types of intracranial hemorrhage are _____.

a. subarachnoid, intracranial, extradural, subdural
b. subarachnoid, intracerebral, extracerebral, subdural
c. subcerebral, intracerebral, extracerebral, subdural
d. subarachnoid, intracerebral, extradural, subdural

18. Which is a true statement of the mastoid process? _____

a. It is part of the external ear.
b. Mastoiditis is an inflammation of any part of the mastoid process.
c. Inflammation of the mastoid process usually affects adults.
d. None of the above

19. Which statement is not true of atherosclerosis? _____

a. It is caused when cells in the arteries are damaged.
b. This condition can be prevented with a low-fat, low-cholesterol
and low-salt diet.
c. It is a rare disorder of the arteries.
d. This condition can be specified to the aorta, the renal artery
or the extremities.

20. The most common condition of glaucoma is _____.

a. open-angle
b. closed-angle
c. angle closure
d. aqueous humor

Assign the accurate diagnostic code for the following conditions. Verify final digits
with the Tabular List and double-check your answers. Each code is worth 3 points.

21. Conjunctivitis of both eyes

_____________________________________

22. Acute posttraumatic stress disorder

_____________________________________

23. Ruptured abdominal aorta

_____________________________________

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24. Delirium tremens

_____________________________________

25. Left otitis media

_____________________________________

26. Paralysis of nondominant lower limb

_____________________________________

27. Unstable angina

_____________________________________

28. Histiocytic leukemia in remission

_____________________________________

29. Background retinopathy

_____________________________________

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Review the documentation provided for each scenario that follows, and then apply
the appropriate ICD-9-CM code(s) to each scenario. Verify final digits with the
Tabular List and double-check your answers. Each code is worth 3 points.

30. Office Visit—Established Patient

SUBJECTIVE
This 63-year-old Hispanic female, who is a long-term insulin-dependent diabetic,
experienced the onset of headache, blurred vision, vomiting and hypotension this morning
after she did not take her morning insulin. The patient has a long-standing history of
hypertension. She denies chest pain or diaphoresis. The patient does not smoke, drink or use
recreational drugs. Medications include insulin and nadolol (Corgard). No prior history of
hepatitis, anemia, pulmonary, renal or gastrointestinal disease. Allergies: NONE.

OBJECTIVE
This is an obese Hispanic female in no acute distress. She is alert, oriented and cooperative.
Heart: 46, regular rhythm. S1 and S2 present without abnormal heart sounds, murmurs. PMI
difficult to assess. Respiratory rate: 16, clear to auscultation bilaterally. Temperature 96.6.
Blood pressure: 130/60. Neck: No JVD. Supple without masses. Abdomen: Bowel sounds
normal. No organomegaly. Abdomen protuberant. Extremities: No edema, cyanosis or
clubbing. Neurologic: Grossly intact.

ASSESSMENT
1. First-degree AV heart block. This may be secondary to nadolol (Corgard).
2. Diabetes mellitus, type 2, requiring insulin adjustment, with long-term insulin use.
3. Hypertension.

PLAN
Fasting and 2-hour postprandial blood sugars, regular insulin p.r.n. until blood sugar adjusted,
discontinue nadolol (Corgard), begin clonidine 0.1 mg t.i.d., stress thallium test, Holter monitoring.

____________________________

____________________________

____________________________

____________________________

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31. PREOPERATIVE DIAGNOSIS

Right tympanic membrane perforation.

POSTOPERATIVE DIAGNOSIS
Right tympanic membrane perforation with acute suppurative otitis media, and
conductive hearing loss.

PRIMARY PROCEDURE
RIGHT EAR EXAMINATION UNDER ANESTHESIA.

INDICATIONS FOR PROCEDURE

The patient is a 15-year-old child with history of a right tympanic membrane perforation,
as well as right conductive hearing loss. Exam in the office revealed a posterior superior
right marginal tympanic perforation. Risks and benefits of surgery including risk of
bleeding, general anesthesia, hearing loss as well as recurrent perforation were discussed
with the mother. The mother wished to proceed with surgery.

FINDINGS AND PROCEDURE

The patient was brought to the room, placed in supine position, given general
endotracheal anesthesia. The postauricular crease was then injected with 1% Xylocaine
with 1:200,000 epinephrine along with the external meatus. An area of the scalp was
shaved above the ear and then also 1% Xylocaine with 1:200,000 epinephrine injected.
A total of 4 mL local anesthetic was used. The ear was then prepped and draped in the
usual sterile fashion. The microscope was then brought into view, and examining the
marginal perforation, the patient was noted to have large granuloma under the tympanic
membrane at the anterior border of the drum. The granulation tissue was debrided as
much as possible. Decision was made to cancel the tympanoplasty after debriding the
middle ear space as much as possible. The middle ear space was filled with Floxin drops.
The patient woke up from anesthesia,was extubated, and brought to recovery room in
stable condition. There were no intraoperative complications. Needle and sponge count
was correct. Estimated blood loss: Minimal.

_____________________________________

_____________________________________

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32. ADMITTING DIAGNOSIS

Congestive heart failure (CHF) with left pleural effusion.

DISCHARGE DIAGNOSIS
1. Congestive heart failure (CHF) with pleural effusion.
2. Hypertension.
3. Prostate cancer, primary.
4. Leukocytosis.
5. Anemia due to neoplastic disease.

LABORATORY AT DISCHARGE
Sodium 134, potassium 4.2, chloride 99, CO2 26, glucose 182, BUN 17, and creatinine
1.0. Glucose was elevated because of several doses of Solu-Medrol given to him
because of bronchospams. Magnesium was 1.8, calcium was 8.1. Liver enzymes were
unremarkable. Cardiac enzymes were normal as mentioned. PT/INR is 1.02, PTT
31.3, white blood cell count 15, 000 with a left shift. This was presumed due to the
corticosteroids. H&H was 32.3/11.3 and platelets 352,000, and MCV was 99. The
patient’s O2 saturations on room air were normal.

HOSPITAL COURSE
The patient was admitted to the emergency room. He has diuresed with IV Lasix. He
was placed on Prinivil, aspirin, oxybutynin, docusate, and Klor-Con. Chest x-rays were
followed. He did have free-flowing fluid in his left chest. Radiology consultation was
obtained for thoracentesis. The patient was seen by Dr. Yang. An echocardiogram was
done. This revealed an ejection fraction of 60% with diastolic dysfunction and periaortic
stenosis with an opening of 1 cm3. An adenosine sestamibi was done in March 20XX,
with a small fixed apical defect but no ischemia. Cardiac enzymes were negative. Dr.
Yang recommended a beta-blocker with an ACE inhibitor; therefore, the lisinopril was
discontinued. The patient felt much better after the thoracentesis. I do not have the details
of this, i.e., the volumes. No fluid was sent for routine studies. Vital signs were stable.

FOLLOW-UP
He will be followed in my office in 1 week. He is to notify if recurrent fever or chills.

PROGNOSIS
Guarded.

DISCHARGE MEDICATIONS
He is being discharged home on Lasix 40 mg daily, potassium chloride 10 mEq daily,
atenolol 25 mg daily, aspirin 5 grains daily, Ditropan 5 mg b.i.d., and Colace 100 mg b.i.d.

_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________

0205502LB03A-25-13 25-55
Medical Coding and Billing Specialist

25-56 0205502LB03A-25-13
 Medical Coding and Billing Specialist
Mail-in Quiz 25
1. Fill in your student ID and your course code below.
For School Use Only:
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2. Be sure your name and address are filled in below.
3. Transfer your answers to this cover sheet.

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NAME
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This Space for Instructor Use  Fold on dotted line

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8. ______________ 18. _______________

9. ______________ 19. _______________

10. ______________ 20. _______________

0205502LB03A-25-13 25-57
Medical Coding and Billing Specialist

21. __________________________

22. __________________________

23. __________________________

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25. __________________________

26. __________________________

27. __________________________

28. __________________________

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__________________________

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25-58 0205502LB03A-25-13
 ICD-9-CM Coding—From Mental Disorders to Circulatory System

Congratulations!
You have completed Lesson 25.

Drive
Terrific
n t !
Quality h me
l i s
o mp
A c c Learn
ing
Skillful

Do not wait to receive the results of your Quiz

before you move on.

0205502LB03A-25-13 25-59
Medical Coding and Billing Specialist

25-60 0205502LB03A-25-13
 Lesson 26

Introduction to
ICD-9-CM
Medical Coding—
Terminology:
From Respiratory System to
Word Parts
Complications of Pregnancy
 Step 1 Learning Objectives for Lesson 26
 When you have completed the instruction in this lesson, you will be trained to do the following:
 Define diseases of the respiratory, digestive and genitourinary systems and
complications of pregnancy, childbirth and the puerperium.

 Explain the exclusions, inclusions and rules related to Chapters 8 through 11

of the Tabular List in the ICD-9-CM manual.

 Identify the diagnoses, outline the coding pathway and assign the final code
for documented disorders and diseases.

 Step 2 Lesson Preview

 Are you well rested and ready to expand your understanding of ICD-9-CM coding?
Great! This is another lesson in which you’ll want to both stay focused and divide your
study time into reasonable “chunks,” because it covers a lot of material. You will be
learning about and working with all the ICD-9-CM codes for Chapters 8, 9, 10 and 11
of the Tabular List. These include the codes for diseases of the respiratory, digestive
and genitourinary systems and the codes for complications of pregnancy, childbirth
and the puerperium.

We’ll be following the same routine that you’ve become accustomed to in recent
lessons—lots of definitions and descriptions of diseases and conditions; explanations to
help you find the correct codes in the Index to Diseases and the Tabular List; and, as
always, plenty of examples and practice exercises for your hands-on practice. So let’s
get started!

0205502LB03A-26-13
Medical Coding and Billing Specialist

To help make sure you don’t get confused as you code the practice
exercises and scenarios throughout the following ICD-9-CM coding
lesson, it’s important to keep in mind that we are focusing for now only
on ICD-9-CM codes—not CPT codes. You will see physician notes and
documentation about specific procedures in some of the scenarios we
use just because we want you to practice with authentic examples. But
remember that you will code only the diagnoses during these lessons—
you’ll have plenty of time and lots of practice combining procedural and
diagnostic codes in later lessons, after you’ve become more familiar and
comfortable with the ICD-9-CM codes.

 Step 3 Diseases of the Respiratory System (460-519)

 We start this lesson with Chapter 8 of the Tabular List, which includes codes
for diseases of the respiratory system. Among the diseases in this chapter are
respiratory infections, other diseases of the upper respiratory tract, pneumonia
and influenza, COPD (chronic obstructive pulmonary disease) and allied conditions,
pneumoconioses and lung diseases and other diseases of the respiratory system. As
with previous lessons and chapters, we move through our review of Chapter 8 by
looking into the code categories within each section.

At the beginning of Chapter 8 in the Tabular List, you are instructed to use an
additional code to identify the infectious organism. This note applies to the entire
chapter. So keep in mind that when you are coding diseases of the respiratory
system, and the infectious organism causing the disease is documented, you must
code for that organism as well as for the respiratory disease.

Acute Respiratory Infections (460-466)

Acute respiratory infections include the common cold, acute sinusitis, acute
pharyngitis, acute laryngitis and acute bronchitis. This section EXCLUDES
pneumonia and influenza, and directs you to use codes 480.0 through 488.19 instead
for those conditions. An important note related to this section has to do with the
term acute. The term might be required, or it may be a nonessential modifier in the
categories included here. You will not find chronic infections in this code category,
and the Tabular List often directs you to the accurate code.

An “acute inflammation of mucous membranes extending from the nostrils to the

pharynx” is termed acute nasopharyngitis, but the condition is known as the
common cold. This category (460) EXCLUDES chronic nasopharyngitis, pharyngitis,
rhinitis and sore throat. Category 465 codes “Acute upper respiratory infections
of multiple or unspecified sites.” This category EXCLUDES upper respiratory
infections due to: influenza and Streptococcus. An upper respiratory infection is
often referred to as a URI—an important acronym to learn and remember.

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ICD-9-CM Coding—From Respiratory System to Complications of Pregnancy

Are you ready to try your hand at coding another scenario, this time relating to a
respiratory system condition? Great—go for it, and see how quickly and accurately
you can complete the coding.

CHIEF COMPLAINT
Respiratory distress and fever x 12 hours.

HISTORY OF PRESENT ILLNESS

This 20-month-old Caucasian male began coughing yesterday, late
afternoon. Fever and coughing were aggravated in the evening. Patient
was given Tylenol and slept well. Today at 8:00 a.m., the patient showed
respiratory distress and increased mucous secretions.

PAST HISTORY
The patient experienced similar symptoms 4 months ago, but they
were relieved spontaneously. The patient is the product of a normal
spontaneous vaginal delivery. Birth weight: 6 pounds 1 ounce.
ALLERGIES: NONE.
Family history: No family history of maternal or paternal diabetes, hypertension
or tuberculosis.

REVIEW OF SYSTEMS
Noncontributory.

PHYSICAL EXAMINATION
VITAL SIGNS: Pulse: 168/min. Respiratory rate: 38/min and labored.
Temperature: 104.4 °F.
HEENT: Increased nasal discharge. Trachea midline. TMs clear. Pharynx
not examined.
NECK: Supple. No jugular venous distention.
CHEST: Heart: Sinus rhythm with tachycardia. No murmurs. Lungs: There is
inspiratory wheezing and respiratory retraction bilaterally. Tachypnea is
present. There are bilateral rhonchi. No area of consolidation.
ABDOMEN: Soft and flat. No organomegaly.
EXTREMITIES: No venous distention.
NEUROLOGIC: No neurologic deficits. Moves all extremities well.

IMPRESSION
Croup. Rule out epiglottitis.

PLAN
NPO. Lateral neck film to rule out subglottic edema. Thirty percent oxygen
mist tent. Racemic epinephrine 0.125 mL in 2.5 mL normal saline. Tylenol
p.r.n. for fever. Intubation precautions until radiographicevidence of
subglottic edema is excluded.

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Medical Coding and Billing Specialist

Let’s briefly review your steps to see how you did. You should have located the
main term Croup in the Index to Diseases for a tentative code of 464.4. You then
determined the highest level of specificity for this condition in the Tabular List
and correctly assigned a final code of 464.4 Croup. Easy, wasn’t it? We’ll just keep
moving forward with the next group of codes, and you’ll soon be breathing easily
because you will have completed your basic review of the respiratory system codes in
the Tabular List.

Other Diseases of the Upper Respiratory Tract (470-478)

Diseases of the upper respiratory tract include diseases of the nose, throat, sinuses,
tonsils and adenoids. You may recall seeing sinusitis, pharyngitis and laryngitis in
the previous section. Remember that the codes in that section cover acute conditions.
You will use this section of the Tabular List for conditions that are not stated as
acute, and some are chronic conditions. As always, using the Index to Diseases
coding pathway will point you in the right direction for identifying the accurate
codes. And you will encounter INCLUDES and EXCLUDES in this section of the
Tabular List, as well, that will assist you in identifying the correct ICD-9-CM codes.

Figure 26-1: Gross Anatomy of the upper respiratory tract

Pneumonia and Influenza (480-488)

Pneumonia is an inflammation of the lungs with consolidation, or the process
of the lungs becoming firm as the air spaces are filled with exudate. Pneumonia
can be classified as viral, bacterial, or due to other specified organisms. Bacterial
pneumonia is treated with antibiotics. Antibiotics will not be effective for viral
pneumonia, however. Determining a viral or bacterial cause for the pneumonia
may be difficult, in which case antibiotics will be prescribed to treat the condition in
case it is bacterial.

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ICD-9-CM Coding—From Respiratory System to Complications of Pregnancy

Pneumonia comes in many forms. We will be discussing three types of pneumonia

that seem to cause confusion in coding. These types are lobular, lobar and lobe
pneumonia. Each type, although it seems to be very similar to the others, has a
different ICD-9-CM code.

Lobular pneumonia, code 485, is primarily known as bronchopneumonia.

This condition is an inflammation of the lungs that usually begins in the terminal
bronchioles. The lungs become clogged with mucopurulent exudate that forms
consolidated patches in adjacent lobules (small lobes). You can see the dark patches
in Figure 26-2.

ICD-9-CM code 481 or 486

ICD-9-CM code 485

Figure 16-2:
Figure Affected
26-2: Areas
Affected of of
areas thethe
Lung
lungWith
withBronchopneumonia,
bronchopneumonia,Lobar
lobar Pneumonia
pneumonia

Lobar pneumonia, code 481 and lobe pneumonia, code 486, look the same
when they are reviewed on an x-ray. Each condition is an inflammation of one or
more lobes of the lung, together with consolidation. The right lung has three lobes
(superior, middle and inferior). The left lung has two lobes (upper and middle).
Lobar pneumonia, code 481, is an acute febrile disease produced by Streptococcus
pneumoniae. This condition is verified by a culture. If the physician notes that the
x-ray reveals right, lower-lobe pneumonia, you will code to 486 because the presence
or absence of streptococcal bacterium is not known. You would code 481 only if
“streptococcal pneumoniae” is documented, or if the physician specifically notes
“lobar pneumonia” in the dictation.

0205502LB03A-26-13 26-5
Medical Coding and Billing Specialist

All right; now that you’ve been introduced to the differences among lobular, lobar and
lobe pneumonias, it’s time to demonstrate your coding skills on the following problem.

SUBJECTIVE
A 47-year-old male admitted to the ED with complaints of fever, chills, and
a painful cough that is producing yellow mucus.
OBJECTIVE
Comprehensive examination performed. Respiratory examination reveals
crackles. Anterior, posterior and lateral chest x-rays ordered.
ASSESSMENT
Results of x-rays confirm right lower lobe pneumonia.
PLAN
Patient admitted for further work-up.

The patient has pneumonia, which is located in the right lower lobe. “Lobular” is not
documented. “Lobar” is not documented. And a culture was not done to check for the
presence of streptococcal bacterium. So you simply have the main term Pneumonia.
This main term in the Index to Diseases provides the tentative code of 486. After
you have determined the highest level of specificity in the Tabular List, you should
assign 486 Pneumonia, organism unspecified as the accurate code.

The other main code group to know more about in this section is 487 Influenza.
Influenza is an acute viral infection that involves the respiratory tract. Influenza is
marked by inflammation of the nasal mucosa, the pharynx and the conjunctiva. The
condition of influenza can be documented “With pneumonia,” “With other respiratory
manifestations” or “With other manifestations.” You will code influenza with any
form of pneumonia as 487.0. You will code influenza not otherwise specified (NOS) or
with laryngitis, pharyngitis or a respiratory infection (upper) (acute) as 487.1. You
will code influenza with involvement of the gastrointestinal tract or encephalopathy
due to influenza as 487.8. Finally, code category 488 is used when influenza is due to
certain identified influenza viruses.

Chronic Obstructive Pulmonary Disease and Allied

Conditions (490-496)
Chronic obstructive pulmonary disease, or COPD, is actually a group of
diseases characterized by ongoing obstruction of the airway. Three common forms of
COPD are acute bronchitis with COPD, chronic bronchitis and emphysema. Acute
bronchitis is a sudden inflammation of the trachea and is typically associated
with a viral URI. When documentation indicates acute bronchitis with COPD, code
491.22 Obstructive chronic bronchitis, With acute bronchitis is assigned.

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ICD-9-CM Coding—From Respiratory System to Complications of Pregnancy

It is not necessary to code 466.0 as the acute bronchitis is included in the code
description for 491.22. Chronic bronchitis is essentially a cough that lasts for at least
three months out of a consecutive two years. In the majority of cases, smoking is the
cause of this condition. Other causes include toxic fumes, air pollution and respiratory
infections. Emphysema is a condition of the lung characterized by an abnormal
increase in the size of air spaces distal to the terminal bronchioles, or destruction
of their alveolar walls. This disease affects cigarette smokers almost exclusively.
Symptoms of chronic bronchitis often, but not always, coexist with emphysema.

Let’s code COPD with acute exacerbation. Using the coding pathway of Disease,
pulmonary, you are directed to see also Disease, lung. The new coding pathway,
Disease, lung, obstructive (chronic), with, acute, exacerbation offers the tentative code
of 491.21. Now, go to the Tabular List to determine the highest level of specificity.
You can comfortably select 491.21 Obstructive chronic bronchitis, With (acute)
exacerbation as the correct code.

Some of the allied conditions (490-496) included in this section are asthma,
bronchiectasis, extrinsic allergic alveolitis and chronic airway obstruction, not
elsewhere classified. Most of these conditions are relatively straightforward to code,
but asthma requires a closer look.

normal bronchial asthma

mucus in lumen
Figure 26-3: Comparison of normal inflammation and basement
bronchus with that in the presence membrane thickening
of bronchial asthma enlarged mucous glands
smooth muscle hyperplasia

Asthma is a condition marked by recurrent attacks of dyspnea with wheezing due

to spasmodic contractions of the bronchi. The Tabular List indicates that code 493
EXCLUDES wheezing, NOS (786.07). Wheezing is a symptom of asthma. So if
wheezing is documented without the final diagnosis of asthma, you will review the
code description for 786.07 and assign it. Category 493 also contains a fifth-digit
subclassification box.

0205502LB03A-26-13 26-7
Medical Coding and Billing Specialist

Review the contents of this box below before you continue.

The following fifth-digit subclassification is for use

with codes 493.0-493.2, 493.9:
0 unspecified
1 with status asthmaticus
2 with (acute) exacerbation

A particularly severe episode of asthma that does not respond to therapeutic

measures is termed status asthmaticus. The physician will document “status
asthmaticus” if you are to use 1 as the fifth-digit subclassification. Likewise, “with
exacerbation” or “with acute exacerbation” will be documented if you are to use 2
as the fifth-digit subclassification. If neither term is documented, you will use 0 as
the fifth-digit subclassification for “unspecified.” In sequencing the codes, if status
asthmaticus were documented with COPD of any type or with acute bronchitis, you
would sequence the status asthmaticus first.

Okay, now that we’ve reviewed the basic information, you’re ready to see how quickly
and accurately you can code the diagnoses based on the following transcribed notes:

SUBJECTIVE
A 12-year-old male presents with a cough for several days. He claims
albuterol is not helping the cough. He denies any real wheezing with this
current illness. His asthma symptoms have been under control this winter.
He has not had a fever with this coughing episode.
OBJECTIVE
He is alert and pleasant. HEENT is unremarkable. He has a very slight
inspiratory crackle and end-expiratory wheeze in his larger airways.
Inspiratory breath sounds are clear. No signs of respiratory distress. Heart
without murmur.
ASSESSMENT
Asthmatic bronchitis.
PLAN
Reviewed his asthma regimen and refilled his Advair Diskus. He continues
on Singulair daily as well as Claritin-D. Recommend he use the albuterol 1-2
inhalations every 4-6 hours for the next couple of days until cough subsides.
Also put him on Zithromax suspension with a double dose on the 1st day.
He is to return if symptoms continue. This young man has a very good grasp
on his asthma, and he is using a peak flow meter appropriately. Peak flows
have been about 100 mL lower than normal.

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ICD-9-CM Coding—From Respiratory System to Complications of Pregnancy

This office visit requires one code for accurate coding. To code the primary diagnosis,
locate the main term Bronchitis in the Index to Diseases. Now, locate the subterm
asthmatic in the Index to Diseases and locate the tentative code 493.90. Note that
status asthmaticus or exacerbation is not documented in the notes, so the fifth digit
of 0 is used for “unspecified.” The notes in the Tabular List for code 493.9 include
asthmatic bronchitis. You will record code 493.90 Asthma, unspecified for this
office visit diagnosis.

Pneumoconioses and Other Lung Diseases due to

External Agents (500-508)
Pneumoconiosis is an inflammation that commonly leads to fibrosis of the
lungs; this disease is caused by the inhalation of dust in various occupations.
Pneumoconiosis is characterized by pain in the chest, a cough with little or no
expectoration, dyspnea, reduced thoracic excursion, sometimes cyanosis and
fatigue after slight exertion. The three types of pneumoconiosis you will most
likely encounter as a medical coding and billing specialist are coal workers’
pneumoconiosis, asbestosis and silicosis.

Coal workers’ pneumoconiosis, formerly known as “black lung” disease, used to

be a deadly killer among miners. With increased health standards in the workplace,
coal workers’ lung disease has been greatly reduced, although not eliminated.
Sometimes called anthracosis, this condition essentially refers to lungs that have
become filled with coal dust. Prolonged inhalation of dust that is rich in carbon
particles and other earth minerals causes the disease. There is no effective treatment
for this disease, and it usually runs a slow but steady course toward lung failure.

Asbestosis is the name given to the lung disease that results from exposure to
asbestos. When asbestos fibers are inhaled, the shorter and smaller ones have
a chance of passing the mucous membranes and reaching the lungs. Once the
fibers enter the alveoli, they are seized by macrophages, and the process results in
extensive pulmonary fibrosis.

Silicosis is the most widespread and oldest of all known

occupational diseases. This environmentally induced
lung disease is caused by the inhalation of tiny
silica crystals found in the dust that is generated
during sand blasting, mining and stone cutting.
Silicosis is characterized by fibronodular lesions
in the lung tissue.

Respiratory conditions caused by fumes, vapors

and aspiration of various other substances are
examples of other lung diseases and conditions referred
to in this section of the Tabular List. For the most part, If you have questions, be sure
these are straightforward diagnostic codes, but if you have to call your instructor!
questions, be sure to call your instructor!

0205502LB03A-26-13 26-9
Medical Coding and Billing Specialist

Other Diseases of the Respiratory System (510-519)

This final section of codes in the “Respiratory System” chapter contains the diseases
and conditions that pertain to the respiratory system that do not fit into any other
section. These diseases and conditions are empyema, pleurisy, pneumothorax,
abscesses and other diseases of the lung. Be sure to review the inclusions, exclusions
and additional notes throughout this section to assist you as you apply these codes.

Code 510, Empyema is pus found within the pleural space. The Tabular List
instructs you to use an “additional code to identify infectious organism (041.0 -
041.9),” and that this category EXCLUDES abscess of the lung. Empyema may
be described with or without mention of a fistula. A fistula in this section is the
passage of the purulent infection from the respiratory cavity to another structure.

Pleurisy, code 511, is an inflammation of the pleura serous membrane of the lungs
and the lining of the thoracic cavity. Often, fluid accumulates at the site of this
inflammation, which results in what is known as pleural effusion. Sometimes, the
pleural effusion is an integral part of the underlying disease. When that is the case,
you assign a code only for the underlying disease. Congestive heart failure (CHF),
for example, would not exist without some degree of pleural effusion. In that case,
you would code only the CHF.

Pneumothorax is the presence of air or gas in the pleural cavity, which results in a
collapsed lung. Let’s look at the subcategories for pneumothorax and air leak. 512.0
Spontaneous tension pneumothorax is a collapsed lung caused by air leaking
from the lung into the lining. 512.1 Iatrogenic pneumothorax occurs when air
is trapped in the lining of the lung following surgery, which in turn causes the lung
to collapse. 512.2 codes to postoperative leaks. Finally, codes found in the 512.8
range cover acute, chronic or conditions EXCLUDES congenital and traumatic
pneumothorax and current tuberculous pneumothorax.

Atelectasis is a condition that may also result in the collapse of a lung. This
condition should not be confused with pneumothorax. The cause of the collapsed
lung with pneumothorax is the presence of gas or air, while the cause of the collapsed
lung with atelectasis is the reduction or absence of air in part or all of the lung.
Atelectasis is coded using 518.0.

It’s time for a Practice Exercise to see how well you understand the information in this
current section. Then you’ll be ready to wrap up the discussion of Chapter 8 and move
forward to Chapter 9 of the Tabular List.

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ICD-9-CM Coding—From Respiratory System to Complications of Pregnancy

 Step 4 Practice Exercise 26-1

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Acute pneumococcal bronchitis

ICD-9-CM code: _______________________________

2. Chronic maxillary sinusitis

ICD-9-CM code: _______________________________

3. Legionnaires’ disease
ICD-9-CM code: _______________________________

4. Chronic asthmatic bronchitis

ICD-9-CM code: _______________________________

5. Adult respiratory distress syndrome

ICD-9-CM code: _______________________________

6. ICD-9-CM Coding Challenge

PREOPERATIVE DIAGNOSIS
Acute respiratory failure.
POSTOPERATIVE DIAGNOSIS
Same.
PRIMARY PROCEDURE
TRACHEOSTOMY.
PROCEDURE
Following informed consent of the patient’s family, the patient was brought to the
operating room and placed supine on the table. After adequate induction of general
anesthesia and application of appropriate monitoring devices, the patient was
prepped and draped for the procedure.

The neck was marked and injected with 5 mL of 1% Xylocaine and epinephrine.
A scalpel was used to create a horizontal incision through the skin. Cautery was
used to control bleeding, and the muscles were split down to the level of the thyroid
isthmus. Blunt dissection was used to dissect between the thyroid isthmus, and it
was divided.

The cricoid cartilage was identified, and the crocoid hook was placed. The inner
space between the 2nd and 3rd thyroid cartilage was then incised, and scissors were
then used to enlarge the incision. A #8 Shiley tracheostomy tube was placed into
the trachea. The cuff was then inflated, and the incision was sutured. The patient
tolerated the procedure well and was transferred back to the ICU.

ICD-9-CM code: ____________________

0205502LB03A-26-13 26-11
Medical Coding and Billing Specialist

 Step 5 Review Practice Exercise 26-1

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 6 Diseases of the Digestive System (520-579)

 The digestive system consists of the organs associated with the ingestion, digestion and
absorption of food. You will progress through this chapter, Chapter 9, of the Tabular
List just as food moves through your body. We begin our discussion at the oral cavity,
and then we move down the esophagus and into the stomach. We discuss diseases of
the stomach and duodenum, which is the first portion of the small intestine. We then
review appendicitis and hernias before we move on to the large intestine. We end our
discussion of coding in this chapter with other diseases of the digestive system.

Chapter 9 includes a number of sections, and we will move at a steady pace from
one section to the next. You can stop at any point and review what you have learned
before you move on to the next section. In other words, pace yourself so that you feel
comfortable with what you’re learning—don’t go so fast that you miss important
details, but don’t go so slowly that you lose momentum and have to go back and
review material more often than necessary.

Diseases of Oral Cavity, Salivary Glands,

and Jaws (520-529)
The oral cavity is the cavity of the mouth and its associated structures, including
the cheek, palate, oral mucosa, glands whose ducts open into the cavity, teeth
and tongue. In looking through the Tabular List for this section, you will find the
diagnosis codes to be straightforward. You also will find some EXCLUDES in this
section. As always, be sure to follow the directions, and you will find the accurate code.

Teeth are the hard, calcified structures set in the alveolar processes of the
mandible, the lower jaw and the maxilla, the upper jaw. During the body’s
development, disorders associated with the teeth may arise, such as an absence of
teeth, a mottling, or spotting with patches of color, of the enamel and premature
eruption or appearance of teeth. Diseases of the teeth include dental caries, abscesses
and gingivitis. Abnormal jaw size, dental arch, or position of fully erupted teeth and
temporomandibular joint disorder are just a few of the anomalies you will find in these
code categories.

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ICD-9-CM Coding—From Respiratory System to Complications of Pregnancy

Dental caries, or cavities, represent Central incis or

one of the most common diseases. They
Late ra l incis or
are bacterial in nature. Dental caries are
a multifactorial disease that involves oral Ca nine (e yeto oth)

bacteria that have eroded the surface enamel Pre mola rs (bic us pid)
of the tooth. The defect spreads down into
Mo lar
the dentin, which becomes decalcified and
disintegrates, so that the bacteria spreads Third m ola r
deep into the tooth and invades the pulp (wis dom to oth)

chamber. Pulpitis, inflammation of the root Hard p alate

canal, affects the nerves and blood vessels Soft p alate
inside the tooth, causing pain. Superficial
Uvula
caries can be treated; but if the infection
spreads to the root canal, abscesses and bone
Crown Enamel
infection of the jaw can develop, requiring
removal of the tooth. To code this condition, Neck Dentin

locate the main term Caries in the Index to Root Pulp

Diseases, followed by the subterm dental. Root canal
cavity

You will find the tentative code of 521.00. Cementum

Checking the Tabular List to determine the Nerve,
artery, Periodontal
highest level of specificity, you will find that vein membrane
the correct code for this condition without Fi 16 4 D t l A t O i
further details specified is 521.00 Dental Figure 26-4: Dental anatomy overview
caries, unspecified.

Did you know that periodontal disease accounts for more tooth loss than dental
caries and all other dental diseases combined? Periodontal disease occurs when
bacteria around the tooth cause plaque to form that then calcifies into tartar. This
process can cause inflammation, swollen gums, and loosening and even loss of teeth.
Poor oral hygiene seems to be the main cause of periodontal disease.

The temporomandibular joint (TMJ) connects the lower jaw to the skull; this
joint is located just in front of the ears. The term TMJ literally refers to the joint
itself, but it also is often used to describe disorders of the joint. TMJ disorder can
be caused by clenching or grinding one’s teeth, poor posture or the lack of relaxation
or sleep. There are many symptoms related to this condition, including popping
sounds, inability to fully open the jaw, jaw pain, headache, earache and toothache.

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Diseases of Esophagus, Stomach, and Duodenum

(530-539)
The esophagus is the portion of the digestive system that extends from the pharynx to
the stomach. The function of the esophagus is to efficiently transport food from the mouth
to the stomach. When diseases of the esophagus occur, this transportation may be painful,
prolonged or nonexistent. Esophageal reflux occurs when there is a backflow of gastric
acids from the stomach to the esophagus, and possibly to the pharynx.

Esophagus F
Fundus

Esophagogastic junction C
Cardia

B
Body of the stomach
Lesser curvature

Greater curvature
Antrum
Rugae
R
Pyloric sphincter Ampulla of Vater

Duodenum (C-loop) Plicae circulares

Duodenal papilla

Figure 16-5:
Figure 26-5:Esophagus,
Esophagus,Stomach
stomachand
andDuodenum
duodenum
16

Operative Report
PREOPERATIVE DIAGNOSIS
Gastroesophageal reflux. Rule out ulcers.
A 52-year-old male presenting with difficulty swallowing and a burning
sensation in epigastric area.
PROCEDURE PERFORMED
ENDOSCOPY.
After patient was adequately sedated by anesthesiologist, a flexible
esophagoscope is passed from the mouth into the esophagus.
Esophageal mucosa appears to be normal. Inflammation consistent with
gastroesophageal reflux. No signs of ulcerations.
POSTOPERATIVE DIAGNOSIS
Gastroesophageal reflux.

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To code this operative report, you will need to ask yourself, “What’s the problem?”
The problem, Reflux, is the main term you will locate in the Index to Diseases. Using
gastroesophageal as the subterm provides the tentative code of 530.81. Now turn to
the Tabular List to determine the highest level of specificity for this code. In the
Tabular List, note that code 530.81 Esophageal reflux EXCLUDES reflux
esophagitis, and indicates that code 530.11 would be more appropriate. Reflux
esophagitis is an inflammation of the lower esophagus due to regurgitated gastric
acid from a malfunctioning lower esophageal sphincter. The operating report does
not note any malfunction, so you can be comfortable assigning code 530.81 for the
condition, which is confirmed by the documentation of the procedure.

An ulcer is a lesion on the mucous membrane that leads to the destruction of the
normal tissue lining. These ulcers are caused by the action of gastric acid and pepsin
on the gastric mucosa, which decreases its resistance to ulcer. This section contains
four categories for ulcers: gastric, duodenal, peptic and gastrojejunal. Gastric ulcers
are those of the stomach. Duodenal and gastrojejunal ulcers are in the small
intestine. The duodenum is the first part of the small intestine. Gastrojejunal
refers to the stomach and the jejunum to the portion of the small intestine located
between the duodenum and ileum. While these categories are locations of ulcers,
the fourth category, peptic, is a type of ulcer. Peptic ulcers can be found in the
esophagus, stomach or duodenum. When the site of the peptic ulcer is not specified,
you will use a code in the category 533. Also note in the Tabular List for these codes
that you are to use an E code for gastric, duodenal and peptic ulcers if the ulcer is
drug-induced, to identify the drug.

The fourth-digit subcategory further identifies an ulcer. Ulcers can be classified

as acute or chronic. Acute ulcers are associated with shallow erosion and
minimal inflammation. They are of short duration and resolve quickly when
the cause is identified and removed. Chronic ulcers are associated with
a long duration and erode through the muscular wall with the formation of
fibrous tissue. It is continuously present for many months or intermittently
present throughout the person’s lifetime. Complications caused by an ulcer
are hemorrhages, perforations and obstructions. To code hemorrhages (or
bleeding ulcers) and perforations (holes in the tissue lining), these conditions
must be noted in the documentation. These complications are confirmed by the
physician’s direct observation using an endoscope.

The size or location of the mucosal ulceration may cause an obstruction of the
digestive system. Code categories 531 through 534 require similar fifth-digit
subclassifications, depending on whether or not an obstruction is documented.

Keep in mind, the physician must document the obstruction; otherwise, you must
apply the fifth digit 0, which indicates “without mention of obstruction.”

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Appendicitis (540-543)
The appendix is described as a worm-like appendage that branches off the large
intestine at the cecum, which is the first part of the colon. You know from your
terminology lessons that the “-itis” suffix means “inflammation of.” So appendicitis
is inflammation of the appendix. Appendicitis begins when the opening from the
appendix to the cecum becomes blocked. Bacteria, usually found within the appendix,
begin to invade the appendix wall, which causes an inflammation. The infection and
inflammation can cause the appendix to rupture. The infection can spread throughout
the peritoneum, or the lining of the abdominal cavity. Alternatively, this infection
can be confined to the area surrounding the appendix, forming a peritoneal abscess.

Large
intestine

Cecum

Appendix

Figure 26-6: Large intestine and appendix

To code appendicitis, you will go to the Index to Diseases and look for the main term
Appendicitis. Using this tentative code of 541, go to the Tabular List to determine
whether this code represents the highest level of specificity for the diagnosis. Based on
the information there, you confirm that code 541 Appendicitis, unqualified is correct.

Hernia of Abdominal Cavity (550-553)

A hernia is the protrusion of a part or structure through the tissues that normally
contain it. This section concentrates on hernias located in the abdominal cavity.
Under the heading for this section in the Tabular List, you will note that it
INCLUDES hernias that are acquired or congenital, except for diaphragmatic or
hiatal hernias. Note in particular that code category 550 includes a fifth-digit
subclassification box to identify whether the hernia is “unilateral or unspecified (not
specified as recurrent),” “unilateral or unspecified, recurrent,” “bilateral (not
specified as recurrent)” or “bilateral, recurrent.” Each of the other hernia codes in
this group, however, list the entire five-digit code, with descriptions, for you.

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Hernias are classified by:

 the location of the hernia, such as the body area, unilateral or bilateral.

 occurrence, such as recurrent or not specified as recurrent.

 documenting with or without obstruction; “with obstruction” can be specified

as incarcerated, irreducible, strangulated or causing obstruction.

 documenting with or without gangrene, which is the death of tissue due to

the obstruction, loss or diminution of blood supply.

Now read through the following note for an office visit by a patient with a hernia,
and then determine how to code the condition.

SUBJECTIVE
A 42-year-old male complains of a lump in the groin, which is tender to the
touch. He states the pain increases when he is lifting.
OBJECTIVE
Abdominal exam confirms inguinal hernia on the right side. Attempt to push
the protrusion back into the abdominal cavity was unsuccessful.
ASSESSMENT
Unilateral inguinal hernia.
PLAN
Outpatient surgery is required for repositioning.

To code this visit, locate the main term Hernia in the Index to Diseases. The type of
hernia is inguinal, so that will be the subterm. Neither gangrene nor an obstruction
is noted in the dictation. Also note that the Index to Diseases states that a fifth digit
is required with code 550.9 0 . Once again, turn to the Tabular List to determine
the highest level of specificity. Based on the fifth-digit sub-classifications included
here, you will select 550.90 as the tentative code for this diagnosis. The hernia
was specified as unilateral but not specified as recurrent. So the final code for
this condition is 550.90 Inguinal hernia, without mention of obstruction or
gangrene, unilateral or unspecified (not specified as recurrent).

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Noninfectious Enteritis and Colitis (555-558)

This small section includes codes for inflammation and insufficiency of the intestines
and inflammation of the colon. Diseases of this type include Crohn’s disease, ileitis,
ulcerative enterocolitis, bowel infarction and gastroenteritis.

Other Diseases of Intestines and Peritoneum (560-569)

This section contains codes for all the remaining diseases and conditions of the
intestine and peritoneum that are not classified within the previous code groups.
Codes 560 through 569 cover conditions such as diverticulosis, constipation,
peritonitis and anal polyp.

You will note that code category 560 lists many EXCLUDES . In other words, you
should not use this category “intestinal obstructions without mention of a hernia” if
a specific cause or reason has been documented.

A diverticulum is a saccular dilatation or outpouching through a weakened area

in the intestinal wall. Diverticula may occur at any point within the gastrointestinal
tract but are most commonly found in the sigmoid colon. Diverticulosis is a
condition in which the person has multiple diverticula. Diverticulitis is an
inflammation of the diverticula. In this section, you will find both of these conditions
associated with both the small intestine and the colon.

Peritonitis is an inflammation of the peritoneal cavity. Turn to the Tabular List to

review the EXCLUDES for code 567. You will see that you do not code from this
category peritonitis with or following abortion, appendicitis or an ectopic or molar
pregnancy. If you have a diagnosis for which you use code 567.0 Peritonitis in
infectious diseases classified elsewhere, you must first code the underlying disease.
Also note that code 567.0 EXCLUDES gonococcal, syphilitic and tuberculous peritonitis.

Now it’s your turn to practice coding again. Read through the following procedure
report, review what you’ve learned so far in this step, and see how accurate you are
at identifying the correct code or codes for the documented diagnosis.

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PREOPERATIVE DIAGNOSIS
Rectal bleeding with history of polyps.
POSTOPERATIVE DIAGNOSIS
Rectal bleeding due to rectal polyp and diverticulosis.
PRIMARY PROCEDURE
TOTAL COLONOSCOPY WITH SNARE POLYPECTOMY IN RECTUM.
DESCRIPTION OF PROCEDURE
This 74-year-old female was taken to the outpatient area, placed in the
left lateral decubitus position, and given 1 mg midazolam hydrochloride
and 60 mcg fentanyl, intravenously titrated by anesthesiologist, with good
sedation achieved. The Olympus video colonoscope was easily introduced
over the cecum and then slowly withdrawn in a spiraling fashion, visualizing
mucosa circumferentially. It was retroflexed in the rectum. The polyp was
biopsied with cold biopsy forceps and then removed in its entirety with the
snare, with cautery current. Good hemostasis was noted at the base. The
polyp was sent for pathologic study. The scope was withdrawn.

To code the diagnosis for this procedure, refer to the postoperative diagnosis. The
patient has rectal bleeding, which is due to the rectal polyp. Because the bleeding
is caused by the polyp, you code only to the rectal polyp. The coexisting diagnosis
is diverticulosis. The procedure indicates the scope was in the cecum, which is the
first part of the colon, so you code diverticulosis of the colon. You would not have that
information if you hadn’t read through the report. So remember that as you review
the physician’s notes to determine correct codes, it is important not only to look at the
postoperative diagnosis, but also to read through the procedure. You must thoroughly
review all the information available to ensure that your coding is accurate.

Okay; let’s walk through the details of this coding example. You identify the primary
coding pathway as Polyp, rectum which provides a tentative code of 569.0. Then, you
refer to the Tabular List to determine the highest level of specificity; you will find
code 569.0 Anal and rectal polyp is the right one.

Next you will follow the pathway of Diverticulosis, colon for the coexisting diagnosis.
Under Diverticula, diverticulosis, diverticulum you will find colon (acquired) with a
tentative code of 562.10. A check in the Tabular List confirms that this is the correct
code: 562.10 Diverticulosis of colon (without mention of hemorrhage).

Remember: In this scenario, the bleeding is due to the rectal polyp, not the
diverticulosis, so you do not associate the bleeding with the coexisting condition.

You’ve come to the final section of diseases of the digestive system. And your coding
skills are starting to show!

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Other Diseases of Digestive System (570-579)

Diseases in this subchapter are those of the liver, the gallbladder and biliary
ducts and the pancreas. The conditions gastrointestinal hemorrhage and intestinal
malabsorption are also included in this code group.
Biliary radicles
Right lobe Hepatic ducts:
Left
Left lobe Right
Common
Common bile duct
F alciform ligament Cystic duct
Gallbladder
Pancreatic duct

Liver, Gallbladder and Biliary Tree, Anterior View

Parietal peritoneum

Inferior vena cava Visceral peritoneum Phrygian cap

Diaphragm Bare area

(not covered
Lig. venos um with peritoneum)
Portal triad:
Caudate lobe
Hepatic artery
Quadrate lobe (anteromedial)
Bile duct
Lig. teres (anterolateral)
Portal vein
(pos terior)
Liver Detail, Pos terior View Infrahepatic Area (liver lifted up), Anterior View

Figure 26-7: Liver, gallbladder and biliary ducts

Code category 571 includes chronic liver disease and cirrhosis, which is end-stage
liver disease. Liver diseases might be the result of alcohol use, or they might not
be alcohol related. Category 572 codes liver abscess and sequelae of, or “condition
following,” chronic liver disease. Other disorders of the liver include hepatitis,
or inflammation of the liver, which is noninfectious. Note that you will code viral
hepatitis from Chapter 1 and code group 070 of the Tabular List.

Cholelithiasis is the presence or formation of gallstones. Gallstones are composed

almost entirely of excessive blood pigment, with calcium deposits in some. This
blood pigment is released by the destruction of red blood cells. This code category,
574, requires use of a fifth-digit subclassification to indicate whether or not an
obstruction is documented. The fifth digit will be 0 if no obstruction is documented,
and 1 with a documented obstruction, as the following box shows:

The following fifth-digit subclassification is for use with category 574:

0 without mention of obstruction
1 with obstruction

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Gallstones may be lodged in the neck of the gallbladder or the cystic duct,
which may lead to an inflammation of the gallbladder. When this happens, the
inflammation is documented, as with cholecystitis. Since these conditions usually
occur together, having a cause-and-effect relationship, one code group, 574, covers
both conditions. Be aware, though, that you will use a specific code category, 574.0,
if the cholecystitis is documented as acute. Also, if only inflammation is documented,
do not assume that the inflammation was caused by cholelithiasis. Finally, you will
use a separate code group, 575, for a diagnosis of cholecystitis alone.

The biliary tract, which you will also code to this section, consists of the organs,
ducts and other structures that participate in the secretion, storage and delivery
of bile into the duodenum. Inflammation, obstruction, perforation and abnormal
passages are disorders associated with the bile duct. Cholangitis is the term used to
indicate inflammation of the biliary ducts.

Let’s code a diagnosis from this section of the “Digestive System” chapter. A patient’s
diagnosis is acute cholecystitis with cholelithiasis. What code would you use to
indicate this condition? Would you have two codes for the two conditions? What main
term would you use for your coding pathway? The answers to these questions will
direct you to the accurate code.

First, you will need to determine the meaning of the diagnosis. Cholecystitis is
an inflammation of the gallbladder. Cholelithiasis is the presence or formation
of gallstones. Remember, these diagnoses indicate a cause-and-effect relationship
that requires one code. For the coding pathway, begin with the inflammation, using
Cholecystitis as the main term. When you look up this term in the Index to Diseases,
you will find “Cholecystitis 575.10,” then “with,” then “calculus, stones in,” and then
“gallbladder — see Cholelithiasis.” So you need to use the cause, or Cholelithiasis,
as the main term. That approach takes you to “Cholelithiasis (impacted) (multiple)
574.2  ,” then “with,” and “cholecystitis 574.  .” The further documentation
of “acute” provides the tentative code of 574.0  . Now turn to the Tabular List
to determine the highest level of specificity. Note that this code has a fifth-digit
subclassification to indicate whether an obstruction is mentioned. It is not, so
574.00 Calculus of gallbladder with acute cholecystitis, without mention of
obstruction is the code you will assign.

You’ve done well with Diseases of the Digestive System. You’re ready to tackle
Diseases of the Genitourinary System after completing a Practice Exercise.

 Step 7 Practice Exercise 26-2

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Ulcerative stomatitis
ICD-9-CM code: _______________________________

2. Acute prepyloric ulcer with hemorrhage

ICD-9-CM code: _______________________________

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Medical Coding and Billing Specialist

3. Chronic peptic duodenal ulcer, with obstruction

ICD-9-CM code: _______________________________

4. Appendicitis with peritonitis

ICD-9-CM code: _______________________________

5. Strangulated hiatal hernia

ICD-9-CM code: _______________________________

6. Impacted colon
ICD-9-CM code: _______________________________

7. Dumping syndrome postgastric surgery

ICD-9-CM code: _______________________________

8. Cirrhosis of the liver

ICD-9-CM code: _______________________________

9. ICD-9-CM Coding Challenge

PREOPERATIVE DIAGNOSIS
Epigastric abdominal pain.
POSTOPERATIVE DIAGNOSIS
Gastritis, gastric ulceration and duodenal ulceration.
PRIMARY PROCEDURE
ESOPHAGOGASTRODUODENOSCOPY WITH BIOPSY.
DESCRIPTION OF PROCEDURE
Following consent, the patient was brought to the endoscopy suite and placed
in the sitting position, where he received Hurricaine spray to his oropharynx.
The patient was placed in the left lateral decubitus position, where a bite-block
was placed between his incisors. The Olympus video gastroscope was placed and
advanced under visualization down through the oropharynx, the proximal then
distal esophagus, through the gastroesophageal junction, and into the gastric body
and duodenum via the pylorus. The endoscope was withdrawn back into the gastric
antrum, and the antral mucosa was biopsied. The endoscope was withdrawn back
into the gastric body, retroflexed with visualization of the gastric fundus. The
endoscope was then straightened and withdrawn completely under suction. The
patient tolerated this procedure very well.

ICD-9-CM codes:

_________________________________

_________________________________

_________________________________

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 Step 8 Review Practice Exercise 26-2

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 9 Diseases of the Genitourinary System (580-629)

 Chapter 10 of the Tabular List includes diseases of the genitourinary system. The
term genitourinary pertains to the genital and urinary organs. The genital and
urinary systems are usually considered together because anomalies of the genital
and urinary tracts are often interrelated. The urinary system includes the kidneys,
ureters, bladder and urethra. We also will discuss the genital system, which
includes the male and female genital organs and the breasts.

Kidney
Extra renal pelvis

Ureter

Bla dder
(behind s ymphys is p ubis )

Urethra

Figure 16-7:
Figure 26-8: Urinary system
System

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Nephritis, Nephrotic Syndrome, and Nephrosis (580-589)

This section deals with diseases of the kidneys. Your terminology lessons will be
helpful in your understanding that the word kidney is renal in Latin and nephros in
Greek. A number of other terms will help you code conditions related to the kidneys.
Note that the section EXCLUDES hypertensive chronic kidney disease. As we
discussed in reference to Chapter 7 of the Tabular List, the ICD-9-CM classification
system presumes a cause-and-effect relationship between hypertension and renal
failure, so you should code these combined diagnoses to code group 403, “Hypertensive
chronic kidney disease” or code group 404 “Hypertensive heart and chronic kidney
disease.” Nephritis is an inflammation of the kidneys. Nephrosis, or nephrotic
syndrome, is a general name for a group of diseases that damage the kidneys.
Symptoms of these diseases include protein in the urine, low blood-protein levels, high
cholesterol levels and swelling.

The kidneys are two bean-shaped organs located in the lumbar region. They filter
the blood, remove ion wastes and toxins and eliminate liquid waste from the body in
the form of urine.

Glomeruli are tufts, or clusters, of capillary loops at the beginning of each

nephric tubule in the kidney. Glomerulonephritis is nephritis accompanied
by inflammation of the capillary loops in the glomeruli of the kidneys.
Glomerulonephritis occurs in acute, subacute and chronic forms, and it might be
secondary to streptococcal infections. Acute glomerulonephritis is typically
preceded by tonsillitis or febrile pharyngitis and is characterized by proteinuria
(protein in the urine), edema, hematuria (blood in the urine), renal failure and
hypertension. A slowly progressive, or chronic glomerulonephritis, generally leads
to irreversible renal failure. Renal failure is the impairment of renal function, either
acute or chronic, with retention of urea, creatinine and other waste products.

Other Diseases of Urinary System (590-599)

Some of the other categories of urinary system diseases, whose codes are
contained in this section, include infection, distention, calculus, inflammation and
malfunctions. Infections of the kidney, bladder and urinary tract are bacterial
infections for which the ICD-9-CM manual directs you to use an additional
code to identify the organism that has caused the infection, if that is known.
Pyelonephritis is an infection of the kidney. Cystitis is an inflammation of the
urinary bladder. A urinary tract infection is referred to as a UTI.

Calculus, or stones, can be found in the kidneys, ureter, bladder, urethra or lower
urinary tract. Kidney stones are the most common. Although kidney stones are
painful, they usually pass on their own without permanent damage. Medication
can be used to decrease the chances of stone formation and to aid in the breakdown
of already-formed stones. If the stones are too large to pass naturally, ultrasonic
waves can be used to break up the stone. Surgery might also be elected for removal
of the stone.

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The urethra is the tube that carries the urine from the bladder to the exterior of the
body. Inflammation of this urinary organ is known as urethritis. An abscess, or
pocket of pus, may form in the tube. A narrowing of the tube is termed a stricture.
As you review the details of this section, note that you are to use an additional code
if this stricture is associated with urinary incontinence.

Carefully review the following operation transcription before you practice coding
the indicated diagnosis. Then we will compare notes to see how you did.

PREOPERATIVE DIAGNOSIS
Left ureteral stone.
POSTOPERATIVE DIAGNOSIS
Same.
PRIMARY PROCEDURE
CYSTOURETHROSCOPY, URETERAL DILATION, AND URETHROSCOPY WITH
STONE EXTRACTION.
PROCEDURE
After general anesthesia was done, the patient was placed in the
dorsal lithotomy position. The genital area was prepped and draped. A
cystourethroscopy was done, which was unremarkable. Under direct vision,
a 0.035-inch guidewire was inserted into the right ureter, all the way to the
renal pelvis. A 4 cm 12 French ureteral balloon dilator was inserted over
the guidewire, and the lower ureter was dilated at 16 mL. After the dilation
was accomplished, the dilator was removed from the guidewire, and the
ureteroscope was inserted into the ureter. The stone could be seen above
the ureterovesical junction. It was engaged into a Segre basket, and
gradually it was removed. Ureteroscopy was done. There was some redness
of the ureteral vault, but it was otherwise unremarkable. The bladder was
drained, and the patient was sent to the recovery room.

For outpatient coding, you are to code the postoperative diagnosis, so you are coding
for a ureteral stone. Go ahead and determine the coding pathway, the tentative code,
and the final code you would assign for this diagnosis before we walk through the
process together.

How do you think you did? Let’s compare notes. You’ll use the coding pathway of
Stone, ureter. The Index to Diseases provides the tentative code of 592.1. Determine
the highest level of specificity in the Tabular List. You can then assign 592.1
Calculus of ureter, which is the accurate code for the diagnosis of left ureteral stone.

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Diseases of Male Genital Organs (600-608)

The primary reproductive organ in the male is the testis (testicle). The job of the
two testes is to produce sperm for reproduction and to produce the male hormone
testosterone. The external organs of the male reproductive system include the
penis and the scrotum. The testes are enclosed by the scrotum. The only portions
of the male reproductive system that are internal are the accessory glands and
the reproductive ducts. The accessory glands include the seminal vesicle, the
prostate gland and the bulbourethral gland. These glands make semen, which
contains sperm. The reproductive duct system includes the epididymis, the ductus
deferens and the urethra. These ducts carry the sperm and semen on their way
out of the body.

Figure 26-9: Male reproductive system

The prostate gland, one of the accessory glands that contributes to the making of
semen, surrounds the neck of the bladder and the urethra. Diseases of the prostate
include enlargement, inflammation, calculus and stricture.

Hyperplasia is an increase in the number of cells in a tissue or an organ, excluding

tumor formation, whereby the bulk of the part or organ may be increased. The
condition of hyperplasia may cause various urinary conditions, in which case you
are directed to use an additional code to identify urinary condition. Keep in mind
that this increase in cells does not correlate with a neoplasm. If the increase in cells
is attributed to malignant or benign neoplasm, you will code from Chapter 2 of the
Tabular List, “Neoplasms.”

Prostatitis is an inflammation of the prostate. If the organism causing the

infection is identified, you are to use an additional code for that organism. When the
inflammation develops suddenly, it is referred to as acute prostatitis. Chronic
prostatitis develops gradually and continues for a long period. Prostatocystitis is
when the inflammation is of the prostate and of the bladder.

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Code category 607, disorders of the penis EXCLUDES phimosis, which is a

narrowness of the opening of the prepuce, or foreskin, preventing its being drawn
back over the glans penis. Disorders of the glans penis, or the head of the penis,
include leukoplakia (white, thickened patches) and balanitis (inflammation of the
glans penis). Other specific disorders of the penis are thrombosis, edema and
impotence of organic origin.

Now that we’ve introduced you to many of the relevant terms and definitions, and a
few coding pointers for this section, let’s try coding an example.

SUBJECTIVE
A 25-year-old male is seen in the office complaining of fever, chills, and lower
abdominal discomfort. He states it is tender between his genitals and anus.
For the past 2 days, he has noted a burning sensation when urinating.
OBJECTIVE
Upon physical exam, prostate is warm and tender. The groin lymph nodes
appear enlarged. The scrotum is swollen and tender. Urethral discharge
is noted. A triple-void urine specimen was taken for urinalysis and culture.
Results of urinalysis indicate elevated WBC. The urine culture shows a
concentration of bacterial growth.
ASSESSMENT
Acute inflammation of the prostate.
PLAN
Patient is discharged with a prescription for Bactrim to be taken for 14 days.

Using the coding pathway of Inflammation, prostate in the Index of

Diseases, You are directed to see also Prostatitis. The new coding
pathway of Prostatitis, acute provides the tentative code of 601.0. The
Tabular List confirms code 601.0 Acute prostatitis as the correct
code. Do you see the relationship between the patient’s sex and
diagnosis? Note that 601.0 is a male diagnosis only.

Know the following terms and related definitions to aid in your understanding
of the physician’s dictation for conditions related to the male genital organs.
And remember: If an infection for any of the following is indicated, you will
use an additional code to identify the organism.

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 Hydrocele—a collection of fluid found in the spermatic cord or in the

space of the tunica vaginalis testis.
 Orchis—a Greek term that means “testis.” Orchitis is an inflammation
of the testis.
 Epididymis—an elongated structure connected to the posterior
surface of the testis. The epididymis stores and matures spermatozoa
and transports them from testis to ductus deferens (vas deferens).
Inflammation of this structure is known as epididymitis.

Disorders of Breast (610-612)

This brief section contains codes for disorders of the breast, which include conditions
classifiable to both males and females. Abnormal tissue growths that are nonneoplastic
in nature (that is, are not neoplasms) are referred to as benign mammary
dysplasias. These conditions are cysts and fibroids of the breast and dilation of the
mammary ducts. These disorders consist of the breast being inflamed or enlarged or a
mass in the breast. Other disorders of the breasts exclude those disorders associated
with lactation or of the puerperium period. The puerperium period is that period of
time that begins immediately following delivery and continues for six weeks.

PREOPERATIVE DIAGNOSIS
Bilateral gynecomastia.
POSTOPERATIVE DIAGNOSIS
Same.
PRIMRY PROCEDURE
BILATERAL SUBCUTANEOUS MASTECTOMY.
PROCEDURE
The patient was brought to the operating room and given 1 mg midazolam
hydrochloride in intravenous incremental doses. The area of concern was
then infiltrated with 1% Xylocaine mixed with 0.5% Marcaine. The area was
infiltrated extensively. An incision was made beneath the nipple of the
right breast, extending down into the skin and subcutaneous tissue. A wide
excision was then taken, grasping all of the breast tissue and completely
dissecting it free. Hemostasis was achieved with electrocautery and suture
ligatures. Dissection was carried up, to include the tail of the breast and
laterally and inferiorly. Hemostasis was determined to be intact. The breast
tissue was removed and sent off as a separate specimen. The wound was
then approximated and closed with interrupted 4-0 Vicryl sutures.
I then proceeded to perform the same procedure on the left breast. This wound
was then approximated and closed with interrupted 4-0 Vicryl sutures. The
patient was awakened and taken to the recovery room in excellent condition.

26-28 0205502LB03A-26-13
ICD-9-CM Coding—From Respiratory System to Complications of Pregnancy

To code the postoperative diagnosis locate the main term Gynecomastia in the
Index to Diseases. The tentative code 611.1 is provided. Turn to the Tabular List
to determine the highest level of specificity. 611.1 Hypertrophy of breast is the
correct code for the procedure documented.

Inflammatory Disease of Female Pelvic Organs (614-616)

The codes for inflammatory conditions of the female pelvic organs that you will
find in this section include inflammation of the ovaries, fallopian tubes, pelvic
cellular tissue, peritoneum, uterus, cervix, vagina and vulva. You will note that
inflammation of the ovary, fallopian tube, pelvic cellular tissue, peritoneum and
uterus are further classified as acute, chronic or unspecified.
Fallopian tube
Ovarian ligament Site of ovum fertilization

Round ligament Ovarian a.

Fimbriae Ovary

Broad ligament ÷ Uterus:

(peritoneum Cornu
draped over Myometrium
uterus, tubes, Endometrial cavity
ovaries) Endometrium
Cervix
Vaginal mucosa covering
serosal surface of cervix Uterine a.

Female beproductive dract, Qnterior fiew

Implantation of embryo

Round ligament Cul-de-sac

(Pouch of Douglas or
Uterus (anteverted) rectouterine recess)
÷
Peritoneum

Vesicouterine recess Xiphoid

process
Bladder

Vagina

Urogenital diaphragm

Clitoris Vaginal
fornix
Labia minora
Cervix
Labia majora
Rectum
36 weeks later

Female `elvis, cagittal `lane

Figure 26-10: Female reproductive system

0205502LB03A-26-13 26-29
Medical Coding and Billing Specialist

Also, note in the Tabular List that you are directed to use an additional code to identify
the organism, if known, responsible for the inflammation. Be aware that these codes
EXCLUDES conditions that are associated with pregnancy, abortion, childbirth or the
puerperium. Finally, you will probably find that reviewing your terminology will be
particularly helpful with this section. For example, salpingo is a combining form for
“tube,” meaning the uterine or fallopian tube; oophoron is Latin for “ovary.”

Here’s another scenario for you to code—see how quickly and accurately you can
determine the correct code, and then compare your results with the summary
that follows.

SUBJECTIVE
An 18-year-old sexually active female complains of vaginal discharge with odor
x 1 month. She has had multiple sex partners in the past 6 months. There has been
pain with intercourse and an increase in menstrual cramping.

OBJECTIVE
Physical exam indicates abdominal tenderness. Pelvic exam reveals cervical
discharge and motion tenderness. Labs requested: WBC, serum HCG,
endocervical culture.

ASSESSMENT
Examination and labs confirm pelvic inflammatory disease (PID).
PLAN
Recommend antibiotic treatment and follow-up appointment in 2 weeks.

Here’s what you should have found in the ICD-9-CM manual for the diagnosis
of PID, or pelvic inflammatory disease. You’ll determine the coding pathway to
be Disease, pelvis, pelvic, inflammatory (female) (PID), with a tentative code of
614.9. Then, go to the Tabular List to determine the highest level of specificity,
and you confirm that 614.9 Unspecified inflammatory disease of female
pelvic organs and tissues is the accurate code.

Other Disorders of Female Genital Tract (617-629)

This final section of Chapter 10 of the Tabular List contains disorders of the female
genital tract, such as endometriosis, genital prolapse, fistula, noninflammatory
disorders of the female genital organs, pain, disorders of menstruation, menopausal
disorders, infertility and other disorders of the genital organs. You might find this
section challenging because of the number of disorders it includes. We discuss the
categories in detail so that you can become comfortable with the information. So
take as much time as you need and be sure you understand each area before you go
ahead to the next section. And, as always, be sure to contact your instructor if you
have any unresolved questions.

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ICD-9-CM Coding—From Respiratory System to Complications of Pregnancy

The endometrium is tissue that lines the uterus. The presence of endometrial
tissue in abnormal locations, such as in the pelvic area, outside of the uterus, or
on the ovaries, bowel, rectum or bladder, is referred to as endometriosis. This
condition can cause pain, irregular bleeding and infertility.

Genital prolapse occurs when pelvic organs bulge into the vagina or cause pelvic
pressure with movement. Prolapse is a hernia and requires surgical repair. When
the bulge causes pressure, urinary incontinence can occur. The ICD-9-CM manual
directs you to use an additional code within code category 618 to identify the urinary
incontinence if it is documented. This group of codes EXCLUDES conditions that
complicate pregnancy, labor or delivery. Also note that prolapse of the vaginal walls
can be classified to the cystocele, urethrocele, rectocele or perineocele. Here’s a brief
review of what these terms mean:
 Cystocele—protrusion of the urinary bladder into the vaginal wall.

 Urethrocele—weakness of the tissues in the front wall of the vagina causing

the overlying urethra to bulge backward and downward into the vagina.

 Rectocele—protrusion into the back of the vaginal wall caused by the

rectum pushing against weakened tissues of the vaginal wall (usually
associated with a cystocele).

 Perineocele—hernia in the perineal region, found between the rectum

and the vagina or the rectum and the bladder, or alongside the rectum.

Pain and other symptoms associated with female genital organs may occur during sexual
intercourse, menstruation or at unexpected times, such as with stress incontinence.
Dyspareunia is pain experienced during sexual intercourse. This pain can occur in the
pelvic area during or soon after sexual intercourse. Causes of this condition range from
vaginal dryness due to inadequate lubrication to current medications.

Pain relating to menstruation can be classified as “pain between periods,” “pain

during periods” or “pain before periods.” Mittelschmerz, or ovulation pain, is
one-sided, lower-abdominal pain that occurs at or around the time of ovulation. This
is not a harmful condition, but often requires treatment to relieve the cramping pain.
Some pain during menstruation is normal. Pain that is severe enough to limit usual
activities or that requires medication is termed dysmenorrhea. Premenstrual
tension syndromes include menstrual migraine, premenstrual dysphoric disorder,
premenstrual syndrome (PMS) and premenstrual tension.

Involuntary leakage of urine due to insufficient sphincter control is referred to as

stress incontinence or urinary incontinence. The leakage may occur upon
sneezing, laughing, coughing, sudden movement or lifting. This incontinence might
be sudden and temporary or ongoing and long term. Strengthening the pelvic
muscles using Kegel exercises can help manage this condition. Surgery might be
required if symptoms continue or worsen.

0205502LB03A-26-13 26-31
Medical Coding and Billing Specialist

By now, you’re probably feeling like a pro in terms of your ability to move around
the ICD-9-CM manual. Quickly assessing each scenario, determining the best
starting place for determining the tentative code, verifying the code, and making
any final adjustments for additional digits as needed in the Tabular List. Go ahead
and complete the following Practice Exercise to review what you’ve learned in this
step before you begin your study of the group of codes that include all the possible
complicating conditions related to pregnancy, childbirth and the puerperium.

 Step 10 Practice Exercise 26-3

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Diabetic nephrosis with long-term insulin use

ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

2. Carbuncle of the kidney

ICD-9-CM code: _______________________________

3. Acute cystitis due to E. coli

ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

4. Hard firm prostate

ICD-9-CM code: _______________________________

5. Testicular abscess
ICD-9-CM code: _______________________________

6. Periodic fibroadenosis of the breast

ICD-9-CM code: _______________________________

7. Paravaginal prolapse
ICD-9-CM code: _______________________________

8. Amenorrhea
ICD-9-CM code: _______________________________

26-32 0205502LB03A-26-13
ICD-9-CM Coding—From Respiratory System to Complications of Pregnancy

Use the following information to complete the CMS-1500 that follows.

9. ICD-9-CM Coding/Billing Challenge

Matthew Grimm, MD Springtown Clinic EIN: 86-8000600

NPI: 0304851124 1824 Park Avenue NPI: 0304455166
Provider of Blue Cross Springtown, CO 80000
and Medicaid 970-555-1834

David Rhodes, MD   
NPI: 0189218600   
Provider of all   
private insurance   

Patient Information
Name Samuel Jones Date of Birth May 19, 1972
Address 3 HWY South Sex M Marital Status Divorced
City Anytown State CO
ZIP 80000
Home Phone (970) 555-1313

Employment Information
Name of Employer Green Finger Nursery
Occupation
If Minor, Name of School

Insurance Information
Primary Insurance Secondary Insurance
Name Blue Cross of Iowa Name none
ID# 666 00 6663 ID#
Group# VE001 Group#
Address PO Box 1677 Address
City Sioux City City
State IA ZIP 51102 State ZIP
Primary Insured Name self Secondary Insured Name
DOB DOB
Relation to Patient self Relation to Patient
Employer Green Finger Nursery Employer
I authorize the release of any information including diagnosis and I authorize the release of any information including diagnosis
treatment. I authorize my insurance carrier to pay directly to the and treatment. I authorize my insurance carrier to pay directly
doctor any benefits otherwise payable to me. to the doctor any benefits otherwise payable to me.

Samuel Jones Signature of patient (or parent of minor child)

Signature of patient (or parent of minor child)

Physician signature: Matthew Grimm, MD

DateofService 2/28/XX
Diagnosis Procedure Charge
99213 Office visit level 3 $63.00
81000 Urinalysis $10.00

Today’s Charge $73.00

Cash/Check $0.00
Balance $73.00

0205502LB03A-26-13 26-33
Medical Coding and Billing Specialist

Samuel Jones
DOB 05 19 1972
Date of Service: 02/28/XX

SUBJECTIVE
This patient complains of dysuria and prostate nodule. Suspect UTI,
rule out pyelonephritis and prostatic carcinoma.

OBJECTIVE
Expanded problem focused exam performed on established patient.
Urinalysis: Specific gravity 1.030, pH 7.4. Negative for protein, glucose
and ketones. Microscopic: No RBCs, WBCs or casts seen. Urine
culture results from outside lab positive for Enterobacter, resistant to
ampicillin and cephalothin.

ASSESSMENT
Urinary tract infection secondary to Enterobacter aerogenes. No
evidence of pyelonephritis or prostatic carcinoma from serologic or
urine testing.

PLAN
Oral antibiotics. Patient to return in 1 week.

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ICD-9-CM Coding—From Respiratory System to Complications of Pregnancy

1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
M F
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
Self Spouse Child Other

CITY STATE 8. PATIENT STATUS CITY STATE

Single Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
Employed
Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State) b. EMPLOYER’S NAME OR SCHOOL NAME
M F YES NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED DATE SIGNED

14. DATE OF CURRENT ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
INJURY (Accident) OR GIVE FIRST DATE
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

17b. NPI FROM TO

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. . 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
FROM TO PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
YES NO $ $ $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 33. BILLING PROVIDER INFO & PH #
DEGREES OR CREDENTIALS (I certify that the statements on the 32. SERVICE FACILITY LOCATION INFORMATION
reverse apply to this bill and are made a part thereof.)

SIGNED DATE a. b. a. b.

0205502LB03A-26-13 26-35
Medical Coding and Billing Specialist

 Step 11 Review Practice Exercise 26-3

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 12 Complications of Pregnancy, Childbirth,

and the Puerperium (630-679)
 Conditions that affect the management of pregnancy, childbirth and the puerperium
are classified in categories 630 through 679 in Chapter 11 of the Tabular List.
Conditions from other chapters usually are reclassified in this chapter when those
conditions either complicate the obstetrical experience or are aggravated by the
pregnancy. Any condition that occurs during the pregnancy is considered to be a
complication of the pregnancy unless the physician documents otherwise. This
chapter contains many fifth-digit subclassification boxes, notes INCLUDES and a
few EXCLUDES . The purpose of this abundance of information is to assist you in
accurately coding all the possible conditions related to pregnancy, childbirth and the
puerperium. Carefully reading the information provided in the Tabular List and
understanding how to apply that information are essential in this chapter. Again, we
methodically walk you through the information provided in each section. We provide
definitions when they are necessary or particularly helpful. We step through
examples and provide plenty of practice to assist you in understanding this chapter.
So take a deep breath, and let’s begin.

ICD-9-CM Guidelines: General Rules for Obstetric Cases

To accurately code Chapter 11 of the Tabular List, you must be familiar with
“Section I ICD-9-CM Conventions, General Coding Guidelines and Chapter-Specific
Guidelines” of the Coding Guidelines in the front of your ICD-9-CM manual. The
following are some of the specific rules to keep in mind, but be sure to review all the
guidelines in detail when you code from Chapter 11 for any patient. We will expand
on these guidelines as we discuss the respective subchapters.
 Codes you find in Chapter 11 have sequencing priority over codes used
in other chapters. You can use additional codes from other chapters in
conjunction with Chapter 11 codes to further specify conditions.

 You are to use Chapter 11 codes only on the maternal record, never on the
record of a newborn.

 Code categories 640 through 649 and 651 through 676 have required fifth
digits, which indicate whether the encounter is antepartum, postpartum or
whether a delivery has occurred.

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ICD-9-CM Coding—From Respiratory System to Complications of Pregnancy

 The fifth digits that are appropriate for each code number are listed in
brackets under each code. In most cases, the fifth digits on each code should
be consistent with each other. That is, for example, if a delivery occurs, all of
the fifth digits should indicate the delivery.

 You should include an outcome of delivery code, V27.0 through V27.9, on

every maternal record when a delivery has occurred. You are not to use these
codes on subsequent records for the mother or on the newborn record.

Ectopic and Molar Pregnancy (630-633)

A molar pregnancy is the result of over-production of the tissue that is supposed
to develop in the placenta. This condition is characterized by a mass of cysts that
resemble a bunch of grapes. A pelvic exam may reveal signs of a normal pregnancy,
although some bleeding may be present. However, because there is no fetus, the size
of the uterus may be abnormally large and there will be no fetal heart tones. Once
the diagnosis is confirmed, if the mass of tissue is not miscarried, it must be removed
by suction curettage, or D and C, which means dilation and curettage.

When a fertilized egg develops outside the uterus, this is called an ectopic
pregnancy. Although the most common site of an ectopic pregnancy is in the
fallopian tubes, it can also occur in the abdominal or pelvic cavity, ovary, uterine
tube or cervix. When a fetus begins to develop outside the uterus, the pregnancy is
not viable, and the fetus must be surgically removed.

Other Pregnancy with Abortive Outcome (634-639)

The format of the Tabular List in this section is different from anything you have
seen to this point. Under the heading for this section is a large shaded box that
indicates the fourth-digit subdivisions for categories 634 through 638.

Let’s look at the box carefully because it’s a little different from what you’re used to.
You will note the fourth digit with the definition. Then, under the fourth digit and
definition are several inclusions to each fourth-digit subdivision. The definition and
inclusions are all listed in this one box at the beginning of the category, so that you can
refer to them when you are coding. If you turn to code category 634, for example, you
will see the definitions provided, but then it is up to you to go back to the box at the
beginning of the section to identify all of the possible inclusions under each fourth digit.

This section also has a fifth-digit subclassification box for categories 634 through
637. Each category lists the box separately, but it’s the same box with the same
meanings in each instance.

The fifth digit for these codes is required to identify the stage of the abortion.
“Complete” indicates that all of the products of conception have been expelled from
the uterus before 20 weeks gestation. “Incomplete” indicates that not all of the
products of conception have been expelled during this time period. “Unspecified”
indicates that the stage of abortion is not specified in the documentation.

0205502LB03A-26-13 26-37
Medical Coding and Billing Specialist

Abortion is the expulsion of an embryo or fetus from the uterus before the stage of
viability. A spontaneous abortion, or miscarriage, is when the loss of the fetus
is the result of natural causes. Therapeutic, elective or legally induced abortions are
intentional or deliberate termination of the pregnancy. Therapeutic abortions
are those recommended by physicians to protect the mother’s health. Elective
abortions are initiated by individual choice, not medical necessity. When the
pregnancy continues despite an attempt to end it by legal means, it is termed a
failed attempted abortion.

To indicate the complication leading to the abortion, you might use additional codes
from categories 640 through 649 and 651 through 659. When used with an abortive
code, you would apply the fifth-digit 3 to codes in these categories, which identifies
“antepartum condition or complication.” Antepartum means before the onset of
labor. You will code complications following abortions using code category 639. This
means you cannot use codes from categories 634 through 638 in conjunction with
category 639.

Complications Mainly Related to Pregnancy (640-649)

This section INCLUDES conditions even if they arose or were present during
labor, delivery or the puerperium. Codes from categories 640 through 649 apply
throughout the entire obstetrical experience, which begins at conception and ends
six weeks after delivery. A fifth digit provides information regarding the current
episode of care. We will explain these fifth-digit classifications in more detail now.

You will use the fifth digits for codes 640 through 649 to
denote the current episode of care. To use these fifth digits
appropriately, you need to know some terminology. Delivery
indicates childbirth, antepartum refers to before onset of labor
and postpartum indicates after childbirth. The fifth digits
you can use with each subcategory code are listed in brackets
under the code. For example, code 640.0 has [0,1,3] under the
code. This means you cannot use a 2 or a 4 as the fifth digit
with code 640.0. Be sure to refer to the information in brackets
before you make your decision when you apply the final digit for
these codes. Also, because multiple coding is common for these
code categories, be certain that the fifth-digit assignments are
consistent with each other.

Pregnancy sometimes creates conditions that might not

otherwise affect the woman. These conditions include
hypertension, diabetes and anemia. These conditions
did not exist before the pregnancy and will likely not
exist after the pregnancy, and so they are known as
gestational or transient. Pregnancy sometimes creates
conditions that might not
otherwise affect the woman.

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ICD-9-CM Coding—From Respiratory System to Complications of Pregnancy

For example, let’s code the diagnosis of pregnancy-induced hypertension, undelivered.

If you begin the coding pathway using Pregnancy as the main term and complicated
(by), hypertension as the subterms, you are redirected to “see Hypertension,
complicating pregnancy.” Turn to the Hypertension table, and locate “complicating
pregnancy.” The term “pregnancy-induced” tells you that the hypertension was not
pre-existing, but was caused by the pregnancy and will probably leave once the baby
is delivered. This condition is gestational or transient. So let’s look for gestational in
the Hypertension table. Once you find gestational, you go to the Unspecified column
and are provided with the tentative code of 642.3. Then turn to the Tabular List
to determine the highest level of specificity. The fifth-digit subclassification box is
located at the beginning of the section. “Undelivered” is specified in the diagnosis, so
you will use the fifth-digit 3 to indicate “antepartum condition or complication.” You
assign 642.33 Transient hypertension of pregnancy, antepartum condition or
complication as the correct code for the diagnosis.

Category 648 includes conditions in the mother that are classifiable elsewhere but
complicate the pregnancy, childbirth or puerperium. When coding 648.2 Anemia,
remember that an additional digit is required and that you should include the
applicable condition classifiable to codes 280 through 285.

Normal Delivery, and Other Indications for Care in

Pregnancy, Labor, and Delivery (650-659)
A normal delivery is the spontaneous, full-term birth of one live baby, delivered
vaginally, head first, with no fetal manipulation or instrumental assistance except
for an episiotomy. An episiotomy is a surgical incision into the perineum and
vagina to prevent laceration at the time of delivery, or to facilitate vaginal surgery.
Be aware that you cannot use code 650 with any other code from groups 630 through
676 because these codes are not within the boundaries of the definition of a normal
delivery. For example, a woman who will be 35-years-old or older at the expected
date of delivery will be coded 659.5  or 659.6  and code 650 will not apply.
V27.0 is the only appropriate code to use with code 650.

Before you try your hand at coding a scenario, here are a few more terms for you to
understand to help you code accurately:
 Gravida—means a pregnant woman. Gravida followed by an Arabic
numeral or preceded by a Latin prefix (primi-, secundi-) designates the
number of pregnancies.

 Gravida 1 or primigravida—refers to a woman in her first pregnancy.

 Gravida 2 or secundigravida—refers to a woman in her second pregnancy.

 Para—means a woman who has given birth to one or more viable

infants. Para followed by an Arabic numeral or preceded by a Latin
prefix (primi-, secundi-, terti-, quadri-) designates the number of times
a pregnancy has culminated in a single or multiple birth.

0205502LB03A-26-13 26-39
Medical Coding and Billing Specialist

 Para 1 or primipara—refers to a woman who has given birth for the

first time.

 Para 2 or secundipara—refers to a woman who has given birth for the

second time to one or more infants.

In our next example, the patient is gravida 2, para 1, which means this is her second
pregnancy and she has given birth once. Carefully read through the delivery notes,
and then see how far you can go in determining the correct code or codes for the
information presented.

DELIVERY NOTE
The patient is a 32-year-old, gravida 2, para 1, at term who presented to labor
and delivery in active labor. The patient’s labor progressed rapidly, and she
was completely dilated at approximately a +2 station. The patient went on
to have a normal spontaneous vaginal delivery over an intact perineum. She
was delivered of a viable female in cephalic presentation, Apgars were 8 at
five minutes and 9 at ten minutes. The birth weight was 3628 gm.
The delivery time was 1628. The placenta delivery time was 1637 and was
spontaneous. The perineum was examined and noted to have no lacerations
of any type. The estimated blood loss at delivery was 300 mL. There were no
complications during delivery.
The patient had a normal spontaneous vaginal delivery without manipulation
or assistance, resulting in a single liveborn infant.

Based on the documentation, you can code this to a normal delivery, code 650,
with a single liveborn as the outcome of delivery, code V27.0. Did you come up
with the same codes? Excellent!

Here are a few more explanations and clarifications to help you as you practice
coding conditions from this section. Indications for care in pregnancy, labor and
delivery include malposition and malpresentation of fetus, disproportion and
abnormality of organs and soft tissues of pelvis. You’ll note in the Tabular List
that these conditions direct you to code first any associated obstructed labor,
and to provide the obstruction code. We will revisit these codes when we discuss
obstructions in the next section.

Known or suspected fetal abnormalities that affect the management of the mother,
in code category 655, are conditions that range from central nervous system
malformations, to chromosomal abnormalities, to decreased fetal movement. Other fetal
and placental problems that affect the management of the mother, in code category
656, include fetal-maternal hemorrhage, Rh incompatibility and intrauterine death.
Keep in mind that you can assign these codes only when the fetal condition is actually
responsible for modifying the management of the mother. Just the fact that the fetal
condition exists does not justify assigning a code from this series to the mother’s record.

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ICD-9-CM Coding—From Respiratory System to Complications of Pregnancy

Polyhydramnios, or hydramnios, is the presence of excess amounts of amniotic

fluid. This code category, 657, instructs you to use 0 as the fourth digit and 0, 1 or
3 as the fifth-digit subclassification. To code the mother’s condition of antepartum
hydramnios, for example, you would locate the main term Hydramnios in the Index
to Diseases. Remember that when you refer to the mother’s condition, so you will
not choose the code for “affecting fetus or newborn.” Instead, you will select the
tentative code of 657.0  . Then turn to the Tabular List to determine the highest
level of specificity. There, you are explicitly instructed to choose 0 as the fourth
digit for this code category. And because this is an antepartum condition, you will
select 3 as the fifth-digit subclassification. So the correct code to assign is 657.03
Polyhydramnios, antepartum condition or complication.

Complications Occurring Mainly in the Course of Labor

and Delivery (660-669)
This section contains codes for conditions such as obstructions, trauma to perineum
and vulva during delivery, complications of the administration of anesthetic or other
sedation in labor and delivery and other complications of labor and delivery, not
elsewhere classified. You will note that the fifth-digit subclassification that applies
to categories 660 through 669 is identical to the fifth-digit subclassifications used
previously in this chapter.

Let’s slow down here and focus carefully as you read through the guidelines for
coding the following conditions. You might even want to highlight this portion so
you can quickly come back to it throughout the rest of your coding practice. You
might want to review this even as you begin coding professionally, until you’re
comfortable with how to apply these codes. The main thing to remember is that
when another condition causes obstruction of labor, you will use an additional code
to identify that condition.
 Code 660.0  Obstruction caused by malposition of fetus at onset
of labor requires an additional code to identify the condition that is
classifiable to code category 652 Malposition and malpresentation of
fetus.

 Code 660.1  Obstruction by bony pelvis requires an additional code to

identify the condition that is classifiable to code category 653, Disproportion.

 Code 660.2  Obstruction by abnormal pelvic soft tissue requires

an additional code to identify the condition that is classifiable to code
category 654, Abnormality of organs and soft tissues of pelvis.

In sequencing these codes, you will code the obstruction (660) first, followed by
the cause. When malposition or malpresentation of the fetus occurs, it can cause
an obstruction.

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Medical Coding and Billing Specialist

A breech delivery, in code category 652, is when the fetal presentation is that of
the buttocks or feet first. This presentation usually causes an obstruction, which
requires assistance during delivery, and sometimes, with manipulation, it can be
converted to cephalic presentation. Remember, with this situation, you will use code
660.0 in conjunction with a code from category 652.

When you’re ready, go ahead and read carefully through the following childbirth-related
operative report, and then, based on the information presented, try your skills at solving
the puzzle to identify the accurate diagnosis code or codes.

PREOPERATIVE DIAGNOSIS
Intrauterine pregnancy at term. Premature rupture of membranes. Frank
breech, causing obstruction.
POSTOPERATIVE DIAGNOSIS
Cesarean delivery due to breech presentation.
PRIMARY PROCEDURE
PRIMARY LOW TRANSVERSE CESAREAN SECTION.
DESCRIPTION AND FINDINGS
The patient underwent an epidural block administered by anesthesiology,
and immediately after that, she was prepped and draped in the usual
manner. A Pfannenstiel incision was used, and the abdominal wall was
then dissected using sharp and blunt dissection. With careful extraction, a
female fetus was then delivered in the frank breech position. Apgars of the
fetus were 8 and 9. Cord was clamped and cut. Blood was drawn from the
infant for type and cross match and Rh factor. The placenta was expressed
manually and visually inspected. The pelvic cavity was then inspected, and
intensive irrigation was carried out. The uterus was closed. Ovaries and tubes
were inspected and noted to be normal. Closure of the abdomen was
accomplished. The skin was then closed with staples. The patient then was
transferred to a recovery room in stable condition.

Are you comfortable with your results? Don’t worry if coding this one took you a
while, or you had a little trouble figuring it all out—the scenario is quite involved,
and you can easily go down the wrong coding pathway until you have had enough
practice and experience working with these code groups. Let’s go through the steps
to solve this puzzle together, and you can see how well you did and, if necessary, get
some pointers that will help you improve your skills for next time.

1. Assess the information and recognize that there are several conditions you need
to be aware of and code for. Try the principal coding pathway of Delivery, breech.
Following this path in the Index to Diseases, you find a tentative code of 652.2  .
You should also note that you must use a fifth-digit subclassification with this
group of codes.

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2. In the Tabular List, you find code 652.2 Breech presentation without
mention of version; the fifth-digit options of 0, 1 and 3 are included in brackets
under the code. From the fifth-digit options given, you should make a mental
note of 1 for “delivered, with or without mention of antepartum condition” as
the fifth digit to assign. You should also note that “Frank breech” is included
as a subterm under code 652.2. Finally, code 652 instructs us to code first
any associated obstructed labor, using code 660.0. Putting all the information
together, you determine that the final code for this part of the diagnosis is
652.21.
3. Next, you focus on the coexisting diagnosis code for obstructed labor, 660.0
Obstruction caused by malposition of fetus at onset of labor. Again, the
fifth-digit options of 0, 1 and 3 are indicated in brackets below this code, and
you already know that the correct fifth digit based on the operative report is
1, “delivered, with or without mention of antepartum condition.” So the final
coexisting diagnosis code is 660.01.
4. You must also include an outcome of delivery V code from codes V27.0 through
V27.9 for the mother’s record. To locate the proper V code, use outcome of
delivery, single, liveborn as the pathway for the tentative code V27.0 Based
on the documentation, you determine that code V27.0 Single liveborn is the
correct code for this portion of the diagnosis.
5. The only thing left to do is put the codes in the correct order. Again, based on the
guidelines in the ICD-9-CM manual, you know that you are to code 660.01 first.
The correct listing of the three codes for this report is 660.01 652.21 V27.0.
You’ve accomplished a lot so far in this lesson! That coding exercise took some
time and careful maneuvering through all the guidelines and instructions we’ve
discussed. Just know that if you are working as a medical coding and billing
specialist in the maternity and childbirth areas, you will have frequent and regular
practice using these codes, and you will quickly become quite familiar with them!

More Pregnancy, Childbirth, and Puerperium

Terminology and Examples
Trauma to the perineum and vulva during the delivery are categorized as perineal
laceration or vulva and perineal hematoma. These conditions INCLUDES both
damage from instruments and that from the extension of the episiotomy. Remember
that an episiotomy is a surgical incision into the perineum and vagina to prevent
laceration at the time of delivery, or to facilitate vaginal surgery. If an episiotomy is
not sufficient in length, the perineum may tear, which can result in a second- to
fourth-degree laceration. If the extent of the perineal laceration is not noted, you will
code to “unspecified.” Otherwise, you will assign one of the following types:
 First-degree perineal—indicates the perineal skin is torn.

 Second-degree perineal—laceration, rupture or tear involves the

perineal muscles.

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Medical Coding and Billing Specialist

 Third-degree perineal—laceration, rupture or tear consists of the

anal sphincter.

 Fourth-degree perineal—laceration, rupture or tear is classifiable to

a third-degree laceration but includes the anal or rectal mucosa.

Figure
Figure16-10:
26-11:Perineal
PerinealLacerations
lacerations

2013 ICD-9-CM Professional for Physicians – Volumes 1 & 2,

Salt Lake City, Utah: Ingenix, Inc. page 207, Volume 1

So let’s say the physician notes excessive fetal growth and performs an episiotomy
during labor to assist the vaginal delivery. Upon delivery, the episiotomy tears,
extending to the vaginal muscles. What would you code for this condition? You
would code the perineal laceration, the excessive fetal growth and the outcome of the
delivery. Let’s do that now.

For the perineal laceration, try a coding pathway of laceration, perineum. In the Index
to Diseases, under Laceration, you find perineum, perineal and then, under that,
complicating delivery. Going further, you find involving and then vaginal muscles,
with a suggested code of 664.1  . Remember that you must also include a fifth digit
to indicate the status of delivery—in this case a 1 for “delivered.” Now you go to the
Tabular List to determine the highest level of specificity, and the information there
confirms our selection of code 664.11 Second-degree perineal laceration, delivered,
with or without mention of antepartum condition as the correct choice.

Next, you will code for the excessive fetal growth. A reasonable coding pathway
is excessive, fetal. You find Excess, excessive, excessively, but fetal isn’t listed as a
subterm. Large, however, is a subterm, and fetus or infant is listed under large. Of
the subterms under fetus or infant, the most appropriate is affecting management
of pregnancy 656.6  . Also remember that you must add the fifth digit of 1 for
“delivered.” Going to the Tabular List, you find 656.6 Excessive fetal growth, and
add the fifth-digit 1, for a final code of 656.61.

Finally, you review the V codes for the correct outcome of delivery code, and
determine that once again V27.0 Single liveborn is the correct choice. Following
the coding guidelines discussed earlier, you will list these codes in the following
order: 664.11 656.61 V27.0.

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Here are some final notes to help you code diagnoses in code groups 668 and 669.
Codes for complications resulting from the administration of anesthetic or other
sedation in labor and delivery, code group 668 INCLUDES those complications that
arise from the administration of general or local anesthetic, analgesic or other
sedation in labor and delivery. It EXCLUDES any reaction to a spinal or lumbar
puncture, as well as a spinal headache. These complications can be pulmonary,
cardiac or central nervous system conditions.

Shock, hypotension and renal failure are conditions that might appear during
or following labor and delivery that you will code to category 669 Other
complications of labor and delivery, not elsewhere classified. Complications
included in category 669 are methods of delivery without mention of indication. This
means the reason the physician selected this type of delivery is not specified. Forceps
or vacuum extractor delivery, breech extraction and cesarean delivery are examples
of these types of complications.

Complications of the Puerperium (670-677)

This section includes a collection of various complications that might occur during
the puerperium. The puerperium is the period of time from the end of the third
stage of labor until the uterus returns to its normal size, which usually requires
three to six weeks. Code categories 670 and 673 through 676 include the listed
conditions, even if they occur during the pregnancy or childbirth. You will find the
fifth-digit subclassification box for code options to denote the current episode of care.
Conditions in this section include major puerperal infection, deep phlebothrombosis,
obstetrical pulmonary embolism, disorders of the breast associated with childbirth
and late effects of complications of pregnancy and childbirth.

Infection and inflammation following childbirth are coded in group 670 Major
puerperal infection. Turn to the Tabular List for additional notes pertaining to
this category. First, you will note that the fourth digit for this category is 0,
“unspecified as to episode of care or not applicable.” You will determine the episode
of care from the fifth-digit subclassification choices of 0, 2 or 4. Infections and
inflammations included in this category are listed. Finally, note the EXCLUDES to
ensure that you code accurately from this section.

Deep phlebothrombosis, or deep-vein thrombosis, is the presence of blood clots

deep in the veins, usually in the leg. Pregnant women have an increased chance of
developing these clots, both antepartum (671.3  ) and postpartum (671.4  ). This
condition becomes life-threatening if one of those clots moves to the lungs and results
in a pulmonary embolism, code 673  .

Infections of the breast and nipple associated with childbirth pertain to the mother
and INCLUDES the conditions present during pregnancy, childbirth or the
puerperium. These conditions include abscess of the nipple and breast and mastitis,
which is an inflammation of the breast tissue. Let’s code the following situation to
give you some practice working with codes in this section.

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SUBJECTIVE
A 26-year-old female is seen by her OB/GYN 2 weeks after giving birth to her
1st child. She complains of pain and swelling of the right breast. She has had
no problem breastfeeding.
OBJECTIVE
Physical exam of breast reveals a lump in the right breast. There is tenderness
when palpating the nodes in the right armpit. She is afebrile.
ASSESSMENT
Mastitis.
PLAN
Recommend moist heat on affected breast for 20 minutes, 4 x a day until
symptoms subside.

With this basic diagnosis, the coding pathway is simply Mastitis. Looking up this
term in the Index to Diseases should give you a tentative code of 611.0. Now turn to
the Tabular List to determine the highest level of specificity, and you will note that
category 611 EXCLUDES mastitis associated with lactation or the puerperium,
which is what you’re coding. So go back to the Index to Diseases and check the
subterms more closely.

You will find puerperal, postpartum (interstitial) (nonpurulent) (parenchymatous) under

Mastitis, and 675.2  
as the tentative code. Turn back to the Tabular List and find
this code. You are now in the category for infections of the breast and nipple associated
with childbirth, so code 675..2  seems right so far. Remember to add a fifth-digit 4
to indicate that the episode of care is a postpartum condition or complication. Because
the delivery occurred two weeks ago, you would not assign a code for the outcome of the
delivery in this case. Based on all the information you have found through this process
and in the Tabular List, you will assign 675.24 Nonpurulent mastitis, postpartum
condition or complication as the correct code.

Once again, you should feel very good about all the hard work you have done, and all
the new information you have learned in this lesson. Now it’s time to complete the
last practice exercise of the lesson to review this last step before you wrap things up
with the Mail-in Quiz.

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 Step 13 Practice Exercise 26-4

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Ovarian pregnancy
ICD-9-CM code: _______________________________

2. Complete miscarriage at 12 weeks

ICD-9-CM code: _______________________________

3. Partial placenta previa with hemorrhage, undelivered

ICD-9-CM code: _______________________________

4. Hyperemesis gravidarum at 20 weeks’ gestation

ICD-9-CM code: _______________________________

5. Normal vaginal delivery of healthy twins

ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

6. Secundigravida, with previous cesarean delivery, delivered a single

liveborn by vaginal delivery
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

7. Third-degree perineal laceration extending to anal sphincter during

delivery of healthy baby girl
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

8. Postpartum pulmonary embolism

ICD-9-CM code: _______________________________

9. Maternal cracked nipple two weeks after delivery

ICD-9-CM code: _______________________________

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10. ICD-9-CM Coding Challenge

ADMITTING DIAGNOSIS
Intrauterine gestation, at term, in active labor.

HISTORY OF PRESENT ILLNESS

This is a 30-year-old, gravida 1, para 0, with unknown LMP and no prenatal care who
came in complaining of contractions and active labor.

DELIVERY NOTE
The patient had ultrasound done on admission that showed gestational age of 38-2/7
weeks. The patient progressed to a normal spontaneous vaginal delivery over an intact
perineum. Rupture of membranes occurred on December 25, 20XX, at 2008 hours
via artificial rupture of membranes. No meconium was noted. Infant was delivered
on December 25, 20XX, at 2154 hours. Prior to rupture of membranes, 2 doses of
ampicillin were given. GBS status unknown. Intrapartum events, no prenatal care. The
patient had epidural for anesthesia. No observed abnormalities were noted on initial
newborn exam. Apgar scores were 9 and 9 at 1 and 5 minutes respectively. There was
a nuchal cord x 1, nonreducible, which was cut with 2 clamps and scissors prior to
delivery of body of child. Placenta was delivered spontaneously and was normal and
intact. There was a 3-vessel cord. Baby was bulb suctioned and then sent to newborn
nursery. Mother and baby were in stable condition. EBL was approximately 500 mL.
NSVD with postpartum hemorrhage. No active bleeding was noted upon deliverance
of the placenta. Upon delivery of the placenta, the uterus was massaged, and there was
good tone. Pitocin was started following delivery of the placenta. Baby delivered vertex
from OA position. Mother following delivery had a temperature of 100.7, denied any
specific complaints and was stable following delivery.

ICD-9-CM code: _________________________________

ICD-9-CM code: _________________________________

 Step 14 Review Practice Exercise 26-4

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

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 Step 15 Lesson Summary

 Do you remember our discussion comparing running a marathon to completing
the previous lesson in this course? We can now expand that analogy and consider
that you’ve completed another major marathon with the completion of this complex
lesson about how to code conditions related to the respiratory and digestive systems,
including all those conditions associated with pregnancy and childbirth. Soon you
will be a star “athlete” when it comes to ICD-9-CM coding skills!

Always remember to balance your time between hard work on these lessons and
enough rest and time away to keep your mind fresh. And continue to review the
basics of everything you’ve studied before you begin a new lesson so you go into the
new material with the previous information fresh in your mind.

Good work on this lesson! Now go ahead and complete the Mail-in Quiz and
you’ll soon be ready to begin a new “chapter” in your medical coding and billing
specialist education!

 Step 16 Mail-in Quiz 26

 Follow the steps to complete the Quiz.

a. Be sure you’ve mastered the instruction and the Practice Exercises that this
Quiz covers.
b. Mark your answers on your Quiz. Remember to check your answers with
the lesson content.
c. When you’ve finished, transfer your answers to the Scanner Answer Sheet
included. Use only blue or black ink on your Scanner Answer Sheet.
d. Important! Please fill in all information requested on your Scanner Answer
Sheet or when submitting your Quiz online.
e. Mail the Answer Sheet to the school via mail, fax or, to receive your grade
immediately, submit your answers online at www.uscareerinstitute.edu.

Mail-in Quiz 26
Choose the best answer from the choices provided. Each item is worth 3.33 points.

1. How are hernias classified? _____

a. By occurrence only
b. Unilateral or bilateral only
c. By location, occurrence, with or without obstruction and with or
without gangrene
d. Incarcerated, irreducible, strangulation or causing obstruction

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2. Which statement is not true of Chapter 11? _____

a. These codes have sequencing priority over codes in other chapters.
b. Chapter 11 codes are used only on the maternal record, never on the
record of a newborn.
c. Fifth digits do not have to be consistent with each other.
d. You should include an outcome of delivery code on every maternal
record when a delivery has occurred.

3. Gravida 3, secundipara means a woman _____.

a. in her third pregnancy, who has given birth to twins
b. in her third pregnancy, who has given birth twice
c. has given birth three times, one stillborn birth
d. has given birth twice and had a hysterectomy

4. _____ means inflammation of the kidneys.

a. Nephritis
b. Renalitis
c. Nephrosis
d. Nephrotic syndrome

5. Pneumonia can be classified as _____.

a. acute or chronic
b. viral, bacterial or due to other specified organisms
c. lobular, lobar or lobe
d. primary or secondary

6. Involuntary leakage of urine due to insufficient sphincter control is

referred to as _____.
a. stress incontinence
b. dyspareunia
c. urinary incontinence
d. Both a and c

7. What is true about TMJ? _____

a. It is the joint that connects the lower jaw to the skull.
b. It is an abbreviation for temporomandibular joint.
c. It is often used to describe disorders of the joint.
d. All of the above

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8. The fourth-digit subcategory for ulcers classifies them as _____.

a. primary or secondary
b. malignant or benign
c. with or without obstruction
d. acute or chronic

9. Where is the duodenum located? _____

a. It is a portion of the stomach.
b. It is the first portion of the small intestine.
c. It extends from the pharynx to the stomach.
d. It is the first part of the colon.

10. _____ is an acute viral infection that involves the respiratory tract.
a. Influenza
b. Pneumonia
c. COPD
d. Pneumoconiosis

11. Which does the acronym “PID” stand for? _____

a. Pelvic Intrauterine Device
b. Pelvic Inflammatory Disease
c. Penile Inflammation Disease
d. Pre-Isolated Dilation

12. Which is not a true statement? _____

a. Cholelithiasis is coded from category 574.
b. Cholelithiasis is an inflammation of the gallbladder.
c. Cholelithiasis requires a fifth-digit subclassification to indicate with or
without obstruction.
d. Cholelithiasis is the presence or formation of gallstones.

13. Which is a true statement of Acute Respiratory Infections (460-466)? _____

a. This subchapter codes for pneumonia and influenza.
b. Acute may be a nonessential modifier.
c. Chronic infections are found in this subchapter.
d. It excludes the common cold.

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14. Which is a true statement of lobar pneumonia? _____

a. The diagnosis code category is 481 or 486.
b. This condition must be verified by a culture.
c. The x-ray reveals dark patches.
d. All of the above

15. Disorders of the Breasts (610-612) applies to _____.

a. females
b. males
c. both males and females
d. disorders associated with lactation

Choose the best diagnostic code(s) from the choices provided.

16. COPD with acute bronchitis _____

a. 466.0
b. 491.22 466.0
c. 491.22
d. 490

17. Asthmatic croup with acute exacerbation _____

a. 493.92
b. 464.4
c. 464.4 493.90
d. 493.90

18. Empyema due to Aerobacter aerogenes _____

a. 492.8
b. 510.9
c. 510.9 041.85
d. 041.85

19. Pneumonia of the left lower lobe, culture confirms Streptococcus

pneumoniae _____
a. 486
b. 482.3
c. 481
d. 481 038.0

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20. Acute duodenal peptic ulcer with perforation _____

a. 532.20
b. 533.10
c. 532.10
d. 533.20

21. Incarcerated scrotal hernia, bilateral _____

a. 550.92
b. 550.12
c. 550.90
d. 550.02

22. Diverticulitis of the jejunum _____

a. 562.00
b. 562.02
c. 562.03
d. 562.01

23. Diabetic nephritis with long-term insulin use _____

a. 583.9
b. 250.40 583.81 V58.67
c. 250.4 581.81 V58.67
d. 250.4 583.81

24. Incomplete miscarriage at 12 weeks gestation complicated by excessive

hemorrhaging requires D&C _____
a. 634.1
b. 634.91
c. 634.11
d. 634.90

25. Pre-eclampsia with pre-existing hypertension, undelivered _____

a. 642.33
b. 401.9 642.73
c. 642.73
d. 401.9

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26. Normal spontaneous vaginal delivery of a healthy baby boy _____

a. 650
b. 650 V27.9
c. 650 V27.0
d. V27.9

27. Spontaneous vaginal delivery complicated by an excessively large

fetus obstructing labor, requiring an episiotomy for delivery of single
liveborn _____
a. 660.11 653.51 V27.0
b. 653.51 V27.0
c. 660.10 653.50
d. 660.10 653.50 V27.0

28. Postpartum hemorrhage of cesarean section wound _____

a. 641.94
b. 674.34
c. 641.84
d. 674.30

29. SUBJECTIVE
The patient is a 38-year-old white male with a 20-year history of alcoholism
and acute pain following a coughing episode on the day prior to the admission.
Following the episode of acute pain, there was brisk hematemesis of dark blood.

OBJECTIVE
The patient was premedicated with Valium 5 mg IV and Demerol 50 mg IV. The
patient was examined with a 1T-10 endoscope. The GE junction was at 38 cm,
and there appeared to be 1+ varices. The stomach was easily distensible with
some blood seen in the fundus. There was a Mallory-Weiss tear with overlying
clots and no active bleeding. There was a prepyloric ulcer seen. The duodenum
and postbulbar region were normal. The patient tolerated the procedure well.
There were no complications.

ASSESSMENT
1. Mallory-Weiss syndrome.
2. Prepyloric ulcer.

PLAN
Treat with H2 blockers and arrange surgical consultation.

a. 786.2 578.0
b. 578.0 530.7 531.90
c. 530.7 531.90
d. 530.7 531.40

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30. SUBJECTIVE
Suspected intussusception. Patient with nausea, vomiting and diarrhea for 2
days. Supine abdomen film shows multiple air-filled loops of bowel. The pattern
is indeterminate for obstruction versus adynamic ileus. ROS is noncontributory.

OBJECTIVE
Abdomen: Rebound tenderness. Abnormal bowel sounds. Genitalia: External
genitalia normal. Database: Barium enema performed to rule out obstruction.
An intussusception was encountered at the level of the transverse colon. The
intussusception was reduced using hydrostatic pressure.

ASSESSMENT
Intussusception, reduced.

PLAN
Repeat abdominal film daily x 3 to look for recurrence.

a. 560.0
b. 787.01 787.91
c. 560.0 787.01 787.91
d. 560.1

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Just for Fun

Before you begin the next lesson, let’s think about the organ systems you’ve studied
so far. You’ve looked at diagrams of different systems such as the respiratory,
digestive and circulatory. You probably know that medical students don’t just look
at pictures of organ systems; they must dissect them as well. Are you too squeamish
to do this? Don’t worry. It’s natural. After a few days, the feeling passes. But thank
goodness all you have to do as a coder is code diagnoses and procedures. The only
things you have to dissect are terms.

You may think that working with organs, dissecting them, handling them and
talking about them would make a doctor callous to the wonder of life. If you forget to
honor your patients, that might happen. The answer lies in attitude.

An important part of medical education is to

remember to honor life and your patients. How do you
do this? You develop the feeling of honor. How does
that feel? Well, if you just learned that you’d won
a prestigious award, you’d probably take in a deep
breath and smile inside. Do that right now. Take in a
deep breath, look at that award and think about how
happy you are inside. It’s such an honor to receive it!

Should you have the opportunity to look at organs,

feel the honor given to you to learn from what was
once a living being. Treat the organs with the respect
they deserve. Make sure they are used for only the
best of intentions. Apply this same feeling to the
honor patients give to you by entrusting you with
their medical information.

Now, let’s get started with your next lesson and learn about even more organ systems.

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Congratulations!
You have completed Lesson 26.

Drive
Terrific
n t !
Quality h me
l i s
o mp
A c c Learn
ing
Skillful

Do not wait to receive the results of your Quiz

before you move on.

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Medical Coding and Billing Specialist

26-58 0205502LB03A-26-13
 Lesson 27

Introduction to
ICD-9-CM
Medical Coding—
Terminology:
From Diseases of the Skin
Word Parts
to Conditions in the Perinatal Period
 Step 1 Learning Objectives for Lesson 27
 When you have completed the instruction in this lesson, you will be trained to do the following:
 Define complications of diseases of the skin, subcutaneous tissue,
musculoskeletal system and connective tissue; congenital anomalies; and
conditions in the perinatal period.

 Explain the basic exclusions, inclusions and rules related to Chapters 12

through 15 of the Tabular List in the ICD-9-CM manual.

 Identify the diagnosis, outline the coding pathway and assign the final code
for the documented disorders and diseases.

 Step 2 Lesson Preview

 In this ICD-9-CM coding lesson, you will encounter a broad mix of diagnosis codes with
lots of tips and pointers to help you select the correct codes. You will learn about diseases
and conditions of the skin, muscles, bones and connective tissue. You will also learn about
congenital anomalies and conditions in the perinatal period. Moreover, you will learn how
to find and confirm the correct codes for these many conditions and diseases. As always,
you will have the opportunity to apply what you are learning as you practice coding the
sample scenarios and exercises provided for you throughout the lesson. So let’s continue
on the journey through the ICD-9-CM manual and diagnosis coding!

To help make sure you don’t get confused as you code the practice
exercises and scenarios throughout the following ICD-9-CM coding
lesson, it’s important to keep in mind that we are focusing for now only
on ICD-9-CM codes—not CPT codes. You will see physician notes and
documentation about specific procedures in some of the scenarios we
use just because we want you to practice with authentic examples. But
remember that you will code only the diagnoses during these lessons—
you’ll have plenty of time and lots of practice combining procedural and
diagnostic codes in later lessons.

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Medical Coding and Billing Specialist

 Step 3 Diseases of the Skin and Subcutaneous

Tissue (680-709)
 Chapter 12 of the ICD-9-CM manual’s Tabular List contains codes for the skin,
which is the largest organ in the body. The skin is the covering that protects all
other organs by acting as a barrier against infection and disease.

The cells of the skin constantly change and adapt to outside influences. Because the
skin is constantly exposed, it is a prime target for infection, inflammation and other
diseases. The skin has a limited reaction pattern to diseases.
This means that it responds to most infections
and diseases by producing the same g
symptoms, such as redness or blistering.

The skin consists of a thick outer s. spinosum

layer, called the epidermis, and a
thicker inner layer, called the
dermis. The skin also includes
appendages, which are structures
that grow within the skin. Skin
appendages are hair, nails and
glands (sebaceous, apocrine and
eccrine). The epidermis continually
forms new cells in its deepest layer
and sheds dead cells at its surface. y
Figure 27-1: Layers of the epidermis
The epidermis contains melanin, the pigment that gives the skin color. The epidermis
or cuticle consists of stratified squamous epithelial tissue. The epidermis of the palms
of the hands and soles of the feet has the following layers: stratum corneum (horny
layer), stratum lucidum (clear layer), stratum granulosum (granular layer),
stratum spinosum (prickle cell layer) and stratum germinativum (basal layer).
The stratum lucidum is present only in the thick skin of the palms and soles.

The dermis or corium consists of

fibrous connective tissue. It is
primarily composed of fibrils of
collagen. Collagen is responsible for
the mechanical strength of the skin.
The dermis is the layer of skin that
lies beneath the epidermis and
consists of the papillary (or
superficial) layer and the reticular
(or deeper) layer. The dermis
contains blood vessels, lymphatics,
nerves, nerve endings, muscle,
hair follicles and sebaceous glands
and sweat glands.

Figure 27-2: Layers of the dermis

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ICD-9-CM Coding—From Diseases of the Skin to Conditions in the Perinatal Period

Infections of Skin and Subcutaneous Tissue (680-686)

This section of Chapter 12 contains codes for infections of the skin and subcutaneous
tissue, which is the layer of loose connective tissue located directly beneath the skin.
These conditions EXCLUDES certain infections of skin classified in Chapter 1 of the
Tabular List, “Infectious and Parasitic Diseases.” Examples of these exclusions are
listed at the beginning of the section. For categories 681 through 683, and for category
686, you are to use an additional code to identify the organism that is causing the
infection if the organism is documented.

A furuncle is a painful nodule formed in the skin by enclosing an inflammation of the

dermis and the subcutaneous tissue enclosing a central core. The furuncle is commonly
known as a boil. A furuncle is caused by staphylococci that enter through the hair
follicles. A carbuncle is an infection of the skin and subcutaneous tissue composed of a
cluster of furuncles, or boils, usually due to Staphylococcus aureus, which results in cell
death. When you code a carbuncle or furuncle, you will code to the site. Note that codes
found in this category, 680 Carbuncle and furuncle contain some EXCLUDES .

Cellulitis is an acute, widely distributed, spreading, fluid-filled, pus-producing,

suppurative inflammation of the deep subcutaneous tissues and sometimes
muscles. This condition may be associated with abscess or localized collection of pus
formation. Again, codes are provided for you to specify the site of the infection. The
following terminology will help you code conditions in this section correctly:
Felon is a painful abscess caused by infection in the closed space of

the fingertip.

 Onychia is an inflammation of the nail matrix that causes nail loss.

 Paronychia is an inflammation of the tissue folds around the nail.

Now that you have some basic definitions and coding information for this section,
let’s put your ICD-9-CM book to work by coding the following scenario:

CT (Computed Tomography) OF NECK

Axial slices were obtained from the base of the skull to the thoracic inlet,
following intravenous contrast infusion. Soft-tissue and bone window
images were obtained for interpretation. There is an irregular fluid
collection seen with adjacent soft-tissue density at the level of the vocal
cord, just medial to the sternocleidomastoid muscle. Further collection
appears to extend superiorly to the level of the hyoid bone and inferior
to the level of the thyroid. Adjacent soft-tissue swelling is seen. There are
several small lymph nodes seen at the left side of the neck. The findings are
consistent with the clinical diagnosis of left deep neck abscess. Remainder
of the findings appear unremarkable.
IMPRESSION
Left deep neck abscess as described above.

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To code this radiology scenario, use the coding pathway of Abscess, neck. Following
this pathway in the Index to Diseases, you find 682.1 as the tentative code. Then,
turning to the Tabular List to determine the highest level of specificity, you find code
682.1 Other cellulitis and abscess, Neck is the correct code.

Other Inflammatory Conditions of Skin and Subcutaneous

Tissue (690-698)
This section contains a variety of diseases with symptoms such as inflamed,
erupting, red, scaly and itching skin. These conditions include seborrheic dermatitis,
contact dermatitis, erythematous conditions, psoriasis and pruritus.

Seborrheic dermatitis is a common chronic disease that affects about 15 percent of

the U. S. population. The symptoms of seborrheic dermatitis are typically reddening,
scaling and itching of the skin, especially under the nose, in the eyebrows and on the
scalp. The skin becomes dry and begins to flake. This condition can be categorized
as “infantile,” “cradle cap” or “unspecified.” On the scalp, this condition is known as
dandruff. To code dandruff, for example, locate that main term in the Index to Diseases,
and you will find the code of 690.18. In the Tabular List, you find 690.18 Other
seborrheic dermatitis. And although dandruff isn’t specified as an inclusion, based
on the Index to Diseases directions, you can be comfortable that this is the correct code.

Contact dermatitis, also referred to as eczema, is an acute or chronic

inflammatory rash marked by itching and redness that is the result of cutaneous
contact with a specific allergen or irritant. This code category, 692, has many
inclusions to assist you with accurate coding. Review the codes carefully when you
are coding from this section.

Psoriasis is a common skin inflammation characterized by the eruption of reddish,

thick, dry, silvery-scaled skin, predominantly on the elbows, knees, scalp and trunk.
This condition is incurable, and treatment is focused on controlling the symptoms. A
specific type of psoriasis, pityriasis rosea is an eruption of macules or papules that
involves the trunk and, less frequently, the extremities, scalp and face. The onset
of pityriasis rosea is frequently preceded, about a week before, by a single, larger,
scaling lesion known as the herald patch, which lasts about six to eight weeks.
Then the lesions, which are usually oval, occur, following the crease lines of the skin.
Spontaneous remission occurs in approximately eight weeks. Treatment for this
condition consists of relieving the symptoms rather than curing the rash.

Other Diseases of Skin and Subcutaneous Tissue (700-709)

This section EXCLUDES conditions that are confined to the eyelids, and congenital
conditions of the skin, hair and nails. The codes here cover corns and calluses,
seborrheic keratosis, nail diseases, hair loss, heat rash, acne, bed sores, hives and
freckles. We will discuss some of these conditions in this lesson.

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ICD-9-CM Coding—From Diseases of the Skin to Conditions in the Perinatal Period

Corns are localized thickening of the skin. They are caused by continuous pressure
over bony areas of the foot, especially the metatarsal head. This frequently causes
localized pain. Shoes that do not fit properly can cause corns. Callosities is commonly
known as a callus. It is an area of thickened skin. It is caused by regular or prolonged
pressure or friction. Gardeners can develop calluses on the palms of their hands,
joggers on the soles of their feet, and guitarists on the tips of their fingers.

Diseases of the nails EXCLUDES congenital anomalies, as well as onychia and

paronychia, which we discussed earlier in this lesson. An ingrowing nail (also often
called an ingrown nail) is a condition that usually affects the toenail, but it can be of
the fingernail, as well. In this condition, one edge of the nail is overgrown by the
nailfold and a pus-forming lesion is produced. Ingrown nails are the result of faulty
trimming of the nails or pressure from a tight shoe on the toenails. You are to use code
681.9 if a general infection of the nail is documented. To code an ingrowing toenail,
simply locate Ingrowing as the main term in the Index to Diseases, and then nail as
the subterm. When you check out the tentative code of 703.0 in the Tabular List, you
will find that 703.0 Diseases of nail, Ingrowing nail is the accurate code.

One condition included in diseases of the hair and hair follicles is alopecia, which
is a lack of hair, or baldness. Baldness is not usually caused by a disease but
instead is influenced by age, genetics and testosterone. The average scalp contains
approximately 100,000 hairs, and it loses about 100 hairs per day. When a hair falls
out, it is replaced within six months with a new one. When the body fails to replace
the fallen hair, this is known as genetic hair loss. Hair loss is a gradual process of
losing hair in patches or over the entire head.

Code group 707 Chronic ulcers of the skin INCLUDES noninfected sinus of the
skin and nonhealing ulcers. This condition EXCLUDES varicose ulcers.

A pressure ulcer (code 707.0), commonly known as a bed sore or a decubitus

ulcer, is an area of skin that breaks down as the result of constant pressure that
reduces the blood supply, which in turn causes the tissue in that area to die. Bed
sores are a common condition for persons confined to beds or wheelchairs.

When coding a pressure ulcer, you are instructed to use an additional code to
identify the pressure ulcer stage, using codes 707.20 through 707.25.

There are four stages of pressure ulcers:

Stage I—Pressure pre-ulcer skin changes are limited to persistent focal erythema.
In this stage, the sores are not opened wounds, although the skin is closed, it can be
very painful. The skin may be warm, firm or stretched.

Stage II—Pressure ulcer may have abrasions, blisters or partial thickness skin loss
involving the epidermis and/or dermis. The skin is tender and painful. Bacteria can
enter the site due to the opened wound.

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Medical Coding and Billing Specialist

Stage III—Pressure ulcer with full thickness skin loss involving damage or necrosis
of the subcutaneous tissue. The skin breaks down and looks like a crater, in which
there is damage to the tissue below the skin. The fat layer is exposed.

Stage IV—Pressure ulcer with necrosis of soft tissues through to the underlying
muscle, tendon or bone. The pressure ulcer is very deep, causing extensive damage.

Let’s practice coding one more diagnosis from this section before you review what
you’ve studied so far. Read through the following report and determine the correct
code or codes for the diagnosis.

PREOPERATIVE DIAGNOSIS
Chronic fourth-stage decubitus ulcer of the right heel.
POSTOPERATIVE DIAGNOSIS
Same.
PRIMARY PROCEDURE
EXCISIONAL DEBRIDEMENT OF SKIN AND SUBCUTANEOUS TISSUE OF HEEL.
PROCEDURE
The patient’s foot was prepped with dilute betadine solution. Following
this, the necrotic tissue surrounding the ulcer was sharply excised through
the skin and the subcutaneous tissue. The tissue was debrided until it
started to bleed around the edge of the ulcer. Adequate hemostasis was
noted. This process was accomplished with minimal local anesthesia, and
the patient tolerated it with little or no pain. The wound was packed with
saline-dampened gauze and wrapped with sterile dressings.

For this operative report, you will choose a coding pathway of Ulcer, decubitus, heel,
which provides the tentative code of 707.07 in the Index to Diseases. Check that
code in the Tabular List and you’ll find it’s correct. Now, you need to identify the
stage of the ulcer. This time your coding pathway is Ulcer, pressure, stage, IV. The
code indicated is 707.24. After verifying this code you will assign 707.07 Chronic
Ulcer of skin, Pressure ulcer, Heel and 707.24 Pressure ulcer stage IV to this
operative report.

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ICD-9-CM Coding—From Diseases of the Skin to Conditions in the Perinatal Period

 Step 4 Practice Exercise 27-1

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Boil located on the back of the right ear

ICD-9-CM code: _______________________________

2. Severe sunburn of face and neck

ICD-9-CM code: _______________________________

3. Eczema due to cat hair

ICD-9-CM code: _______________________________

4. Lupus erythematosus
ICD-9-CM code: _______________________________

5. Perianal itch
ICD-9-CM code: _______________________________

6. Baldness
ICD-9-CM code: _______________________________

7. Patient is hemiplegic due to cerebrovascular disease presenting with

stage II pressure ulcer located on buttocks, resulting from contact
with wheelchair.
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

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Medical Coding and Billing Specialist

Use the following information to complete the CMS-1500 that follows.

8. ICD-9-CM Coding/Billing Challenge

Sarah Duncan, MD SSN: 333-33-0003

1414 Swallow Street NPI: 0203048901
Yourtown, CO 80000 Participating Provider for
(970) 555 -1514 Blue Cross, Mutual Life and Medicare

Patient Information
Name Emma Smith Date of Birth 1-30-30
Address 1410 Iris Drive Sex F Marital Status widowed
City Mytown State CO
ZIP 80001
Home Phone 970-555-5843

Employment Information
Name of Employer retired
Occupation
Student Full time Part time

Insurance Information
Primary Insurance Secondary Insurance
Name Medicare Name none
ID# 501 00 7319A ID#
Group# Group#
Address 600 Grant Street Ste 600 Address
City Denver City
State CO ZIP 80203 State ZIP
Primary Insured Name Emma Secondary Insured Name
Relation to Patient Relation to Patient
DOB DOB
Employer Employer
I authorize the release of any information including diagnosis and I authorize the release of any information including diagnosis
treatment. I authorize my insurance carrier to pay directly to the and treatment. I authorize my insurance carrier to pay directly
doctor any benefits otherwise payable to me. to the doctor any benefits otherwise payable to me.

Emma Smith
Signature of patient (or parent of minor child)
Signature of patient (or parent of minor child)

Physician signature: Sarah Duncan, MD

DateofService 7/12/XX
Diagnosis Procedure Charge
99212 Office visit level 2 $50.00

Today’s Charge $50.00

Cash/Check $0.00
Balance $50.00

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ICD-9-CM Coding—From Diseases of the Skin to Conditions in the Perinatal Period

Emma Smith
DOB 01 30 1930
Date of Service: 7/12/XX

SUBJECTIVE
Patient developed “infection in my cuticle.” The patient gets regular
acrylic manicures. Washes hands 1 or 2 x a day. Otherwise, no
excessive exposure to water or detergents.

OBJECTIVE
Vital signs are normal. There is redness and swelling of the
perionychium at the base of the right index finger. The nail is raised,
and there is suppuration present.

ASSESSMENT
Paronychia.

PLAN
Incision and drainage. Culture and sensitivity. Cephradine 500 mg p.o.
t.i.d. for 10 days. Return in 3 days for observation and results
of culture.

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Medical Coding and Billing Specialist

1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
M F
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
Self Spouse Child Other

CITY STATE 8. PATIENT STATUS CITY STATE

Single Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
Employed
Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State) b. EMPLOYER’S NAME OR SCHOOL NAME
M F YES NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED DATE SIGNED

14. DATE OF CURRENT ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
INJURY (Accident) OR GIVE FIRST DATE
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

17b. NPI FROM TO

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. . 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
FROM TO PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
YES NO $ $ $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 33. BILLING PROVIDER INFO & PH #
DEGREES OR CREDENTIALS (I certify that the statements on the 32. SERVICE FACILITY LOCATION INFORMATION
reverse apply to this bill and are made a part thereof.)

SIGNED DATE a. b. a. b.

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ICD-9-CM Coding—From Diseases of the Skin to Conditions in the Perinatal Period

 Step 5 Review Practice Exercise 27-1

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 6 Diseases of the Musculoskeletal System and

Connective Tissue (710-739)
 Chapter 13 of the Tabular List contains codes for diseases, disorders and pains
of the joints, bones and cartilage located in the musculoskeletal system, as
well as acquired musculoskeletal deformities. The musculoskeletal system
is composed of the skeletal system and the muscular system because they work
closely together. The skeletal system is the “backbone” of the body, while the
muscular system consists of tissues that produce movement anywhere in the
body by contracting and relaxing. Connective tissues bind together and support
various structures of the body.

At the beginning of Chapter 13 of the Tabular List, you will find a fifth-digit
subclassification box to be used with codes in categories 711 through 712, 715
through 716, 718 through 719 and 730. The fifth-digit subclassification indicates
the affected site. You will refer to this box often when coding from the sections of
Chapter 13. You are also instructed to use an additional external cause code to
identify the cause of the musculoskeletal condition if applicable.

Arthropathies and Related Disorders (710-719)

You will find codes for diseases that affect the joints and disorders related to these
conditions in this section. The section includes codes for diseases of the connective
tissue, infections of the joints, rheumatoid arthritis, osteoarthritis, derangement and
other disorders of the joints. The codes in this section EXCLUDES disorders of the
spine, which are included in the next section. Systemic lupus erythematosus,
also referred to as SLE or lupus, is a chronic inflammatory disease of the connective
tissue that can affect many organ systems. Characteristics of this disease include
fever, weakness, muscle and joint pain, anemia and a “butterfly” rash around the
cheeks and forehead. There is no cure for SLE. Treatment focuses on the symptoms.

Because SLE can affect many organ systems, you are to use an additional code to
identify the manifestation. To code systemic lupus erythematosus, locate the main
term Lupus in the Index to Diseases, where you will find the tentative code of 710.0.
If you look down the list of subterms, you will find that erythematosus, systemic
provides the same code. Turn to the Tabular List to determine the highest level of
specificity. Based on the information here, you will see that 710.0 Diffuse disease
of connective tissue, Systemic lupus erythematosus is the correct code.

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“Arthropathy associated with infections” refers to any infectious disease that affects a
joint. This code category EXCLUDES rheumatic fever, which you will code from
category 390. Crystal arthropathies are joint diseases caused by urate, or salt of
uric acid, crystal deposits in joints or synovial membranes. This category EXCLUDES
gouty arthropathy, codes 274.00-274.03.

You will note a modified fifth-digit subclassification box in each of these

sections. The box is a condensed version of the box located at the beginning of
Arthropathies and Related Disorders.

Although the box lists fifth-digits to specify the sites, refer to the beginning of the
chapter for more detailed information so you are sure your coding is accurate. Most
conditions you will find in each of these categories are manifestations of underlying
diseases. For this reason, you are directed to code the underlying disease first.

Rheumatoid arthritis, or RA, is a chronic systemic disease characterized by

recurrent inflammation of the synovial joints and related structures. Onset may
be abrupt, with simultaneous inflammation in multiple joints, or gradual, with
progressive joint involvement. The most sensitive physical sign is the tenderness
in nearly all of the inflamed joints. Symmetric involvement of small hand joints,
feet, wrist, elbows and ankles is typical, but RA may occur in any joint. This
condition occurs more often in women than men. The course is variable but often
is chronic and progressive, and leads to deformities and disability. The treatment
for RA includes medication, physical therapy and even surgery to relieve some of
the symptoms.

Now read through the following SOAP note and determine the correct code for
the diagnosis:

SUBJECTIVE
Patient states, “My hands hurt.” She rated the pain as 7 on a scale of 1-10,
with 10 being the most severe pain.
OBJECTIVE
Observed swelling and inflammation in fingers and joints of both hands
and wrists. Range of motion and strength decreased substantially. Paraffin
bath given bilaterally for hands and wrists, with some improvement noted.
Therapeutic activities performed for 15 minutes to improve ADLs. A 4 x 4
inch piece of dicem was given to patient to assist with opening jar lids,
and a rocker knife was given to assist patient with cutting when preparing
meals. She was instructed in the use of both items.
ASSESSMENT
Rheumatoid arthritis in hands and wrists bilaterally.
PLAN
Patient to return in 1 week for occupational therapy to reevaluate
treatment plan and progress.

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ICD-9-CM Coding—From Diseases of the Skin to Conditions in the Perinatal Period

To code the diagnosis of rheumatoid arthritis, you begin, as always, in the Index
to Diseases. Following the coding pathway of Arthritis, rheumatoid, you will
identify a tentative code of 714.0. Now turn to the Tabular List to determine
the highest level of specificity, where you will confirm that 714.0 Rheumatoid
arthritis is the accurate code for the scenario.
Osteoarthritis, also known as degenerative
joint disease, is a noninflammatory
degenerative joint disease characterized
by the repair of joint cartilage not Quadriceps tendon
keeping up with cartilage degeneration.
This condition tends to occur in the
Synovial capsule
weight-bearing joints, such as the knees
and hips. The exact cause of osteoarthritis
is unknown, but it is believed that metabolic, (Patella)
genetic, chemical and mechanical factors
play a role, as well as the aging process. Articular surface

Meniscus
Derangement is the disturbance of the (fibrocartilaginous disk)
regular order or arrangement. Category 717 Patellar ligament
includes codes for the internal derangement
of the knee. This code group INCLUDES Ligaments
degeneration, rupture and old rupture or tear
of the articular cartilage or meniscus of the
knee, and EXCLUDES current injury,
deformity and recurrent dislocations. Joint
mice of the knee indicates the presence of
small, calcified, loose bodies in the joint Figure
Figure27-3:
17-3:Knee joint,
Knee ligaments
joint, andand
ligaments tendon
tendon.
synovial area. To code this condition, use the
coding pathway Joint, mice in the Index to
Diseases. This pathway directs you to see
Loose, body, joint, by site. This new coding
pathway, Loose, body, joint, knee, provides the
tentative code of 717.6. When you turn to the
Tabular List to determine the highest level of
specificity, you will confirm that 717.6 Internal
derangement of knee, Loose body in knee is
the accurate code for this condition.

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Dorsopathies (720-724)
Dorsopathy is a general term for diseases and disorders of the spine. Inflammation,
stiffening, displacement and degeneration are a few of the conditions you will
find within this section. This is a fairly straightforward section to code from, but
understanding the anatomy of the spine will assist you with accurate coding.

The spine is called the vertebral column because it is

composed of a stack of 33 vertebrae, which are divided
into 5 distinct regions. There are 7 cervical vertebrae,
numbered C1 though C7; 12 thoracic vertebrae,
numbered T1 through T12; 5 lumbar vertebrae,
numbered L1 through L5; 5 fused sacral vertebrae,
numbered S1 though S5; and 4 fused coccygeal,
vertebrae forming the coccyx.

Intervertebral discs form the major joint at each

level of the spine. These discs cushion the vertebrae
from the shock of weight-bearing movements by the rest
of the body. The discs also allow the spine to bend. A
disorder of the discs without a disorder of the spine is
specified as “without myelopathy.” As the spine flexes
and extends, the discs protect the vertebral bodies from
injury. Injuries to the discs include displacement and
degeneration. Displacement, or the lack of normal
positioning, may also be referred to as herniation. When
you locate Herniation in the Index to Diseases, you are Figure 27-4: Vertebral column
directed to see also Hernia. The coding pathway Hernia,
intervertebral cartilage or disc redirects you to see
Displacement, intervertebral disc.

Let’s code hernia of the L4-L5 intervertebral disc. With your anatomy knowledge, you
know that L4-L5 refers to the lumbar region. So let’s look up Hernia, lumbar in the
Index to Diseases. This coding pathway provides the tentative code of 553.8.
That code is in the range for the “Digestive System” chapter—that’s not right! Go
back to the Index to Diseases and continue from the Hernia, lumbar pathway to the
subterm intervertebral disc. This provides the tentative code of 722.10. You then turn
to the Tabular List to determine the highest level of specificity. You can comfortably
conclude that 722.10 Intervertebral disc disorder, Displacement of thoracic or
lumbar intervertebral disc without myelopathy, Lumbar intervertebral disc
without myelopathy is the accurate code.

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ICD-9-CM Coding—From Diseases of the Skin to Conditions in the Perinatal Period

Rheumatism, Excluding the Back (725-729)

Rheumatism is an indefinite term applied to various conditions marked by
inflammation and degeneration or metabolic derangement of the connective tissue
structures of the body. Its symptoms include pain, stiffness or limitation of
movement. When rheumatism affects only the joints, it is called arthritis. This
section does not include codes for conditions of the back because they are included in
the previous section. It INCLUDES disorders of muscles, tendons and other
attachments and of other soft tissues. You’ll find that most coding in this section is
straightforward. Fourth and fifth digits are provided in the Tabular List. Be sure to
review each tentative code to verify inclusions, exclusions and additional notes that
will assist you.

Let’s go straight to the sample physician notes so you can practice coding the
diagnosis. Work carefully but as quickly as you can, and then we’ll review the
process to see how you did.

SUBJECTIVE
This 16-year-old male has experienced mild pain in the back of his lower
heel that increases when he is playing basketball. The season just started,
and he admits to being out of shape.
OBJECTIVE
Physical exam reveals swelling of the back of the leg. Palpation notes a
hard knot of tissue.
ASSESSMENT
The patient suffers from Achilles tendinitis.
PLAN
An MRI is scheduled to determine the extent of the injury. He is to follow up
in this office in 2 weeks to review the MRI results.

The diagnosis seems straightforward enough—let’s see if the code is also. Use the
coding pathway of Tendinitis, Achilles. In the Index to Diseases, you find a tentative
code of 726.71. Turn to the Tabular List to determine the highest level of specificity.
You find code 726.71 Peripheral enthesopathies and allied syndromes,
Enthesopathy of ankle and tarsus, Achilles bursitis or tendinitis is the
correct code.

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Medical Coding and Billing Specialist

Osteopathies, Chondropathies, and Acquired

Musculoskeletal Deformities (730-739)
The final section of the “Musculoskeletal System and Connective Tissue” chapter
deals with osteopathies, chondropathies and acquired musculoskeletal deformities.
Osteopathy is any disease of the bone, while chondropathy is any disease of the
cartilage. Acquired musculoskeletal deformities are deformities not present at birth.

Code category 730 Osteomyelitis, petriostitis, and other infections involving

bone EXCLUDES the jaw (526.4-526.5) and the petrous bone (383.2). You are
directed to use an additional code if the organism causing the infection is identified.
Again, the condensed version of the fifth-digit code subclassifications is provided.
The list at the beginning of the chapter contains the definitions for these fifth digits.

Osteomyelitis is an inflammation of the bone tissue and marrow caused by a pus

forming organism. Periostitis is an inflammation of the periosteum, or the thick,
fibrous membrane that covers the entire surface of a bone. Acute osteomyelitis can
be documented as acute or subacute, and with or without periostitis. Chronic
osteomyelitis EXCLUDES aseptic necrosis of the bone (733.40-733.49). If osteitis or
osteomyelitis is not otherwise stated, you will code the condition as unspecified.

Category 733 Other disorders of the bone and cartilage contains a broad
spectrum of disorders. Osteoporosis and pathological fractures are two conditions
that we will discuss. Be sure to read through the notes, inclusions and exclusions in
the Tabular List when you are coding from this section.

Osteoporosis is a commonly occurring bone disease characterized by a reduction in

bone mass. Senile osteoporosis accounts for most cases of this disease. It affects
persons older than age 70, and is due to the natural aging process. When there is
no apparent cause for the disease, it is termed idiopathic osteoporosis. Disuse
osteoporosis is defined as localized or generalized bone loss that results from the
reduction of mechanical stress on bones. In other words, this condition is caused by
prolonged inactivity that results in loss of bone mass. This inactivity may be due to
bed rest, paralysis or casting. Osteoporotic bones become thin and brittle, making
them prone to fractures.

A fracture is a break or rupture in a bone. Traumatic fractures occur because of

mechanical injury. We will discuss this type of fracture in a later lesson. Pathological
fractures, or spontaneous fractures, occur without major external trauma.
Pathological or spontaneous fractures are the result of the bone structure weakening
by a pathological process, such as occurs with osteoporosis and neoplasms.
Subcategory 733.1 Pathologic fractures EXCLUDES stress fracture, which you
will code from codes 733.93 through 733.95, and traumatic fracture, which you will
code from codes 800 through 829. Stress fractures are caused by unusual or repeated
stress on a bone. Athletes frequently experience stress fractures.

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ICD-9-CM Coding—From Diseases of the Skin to Conditions in the Perinatal Period

As mentioned, acquired musculoskeletal deformities are those that are not genetic.
Conditions that exist at birth, such as mental or physical traits, anomalies,
malformations or diseases, and that might be either hereditary or the result of an
influence during gestation up to the moment of birth, are termed congenital. We
will discuss congenital anomalies in the next chapter, but it is important to
understand the difference between the two to accurately code this section. You will
note that each code category from 735 through 738 EXCLUDES a type of congenital
condition. The acquired deformities you will be coding in this section include
hammer toe (acquired), club hand (acquired), swan-neck deformity, bowleg
(acquired), claw foot (acquired), scoliosis and deformity of the nose (acquired). You
should be able to determine whether the condition is congenital or acquired by the
documentation in the medical record.

We’ve covered quite a bit of information since your last Practice Exercise. Let’s stop
and give you a chance to review the material. Then you can complete the following
coding exercises to see how well you understand the material in this section.

 Step 7 Practice Exercise 27-2

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Arthralgia of the left shoulder

ICD-9-CM code: _______________________________

2. Herniation of C4-C5
ICD-9-CM code: _______________________________

3. Calcification of the cervical disc

ICD-9-CM code: _______________________________

4. Lower back pain

ICD-9-CM code: _______________________________

5. Bursitis of the right hip

ICD-9-CM code: _______________________________

6. Acquired trigger finger

ICD-9-CM code: _______________________________

7. Infective myositis
ICD-9-CM code: _______________________________

8. Idiopathic osteoporosis
ICD-9-CM code: _______________________________

0205502LB03A-27-13 27-17
Medical Coding and Billing Specialist

Use the following information to complete the CMS-1500 that follows.

9. ICD-9-CM Coding/Billing Challenge

FRONT RANGE FAMILY CARE ______ Greg Stephen, MD NPI: 0267679942

1800 Circle Court __X___ Donald Milford, MD NPI: 0810998051
Yourtown, CO 80000 ______ Douglas Smart, MD NPI: 0144878804
(970) 555-3344 Group NPI: 0881099885
Patient Information
Name Janet Scott Date of Birth November 11, 1985
Address HQ USAF SP PSC 5 Sex F Marital Status married
City Ellsworth AFB State SD
ZIP 57706
Home Phone 605-555-6330

Employment Information
Name of Employer Harrison Elementary School
Occupation Administration
If Minor, Name of School

Insurance Information
Primary Insurance Secondary Insurance N/A
Name TRICARE Name
ID# 352005515 ID#
Group# Group#
Address PO Box 100502 Address
City Florence City
State SC ZIP 29501-0502 State ZIP
Primary Insured Name James Scott Secondary Insured Name
Relation to Patient Spouse Relation to Patient
DOB 9/13/1985 DOB
Employer USAF Employer
I authorize the release of any information including diagnosis and I authorize the release of any information including diagnosis
treatment. I authorize my insurance carrier to pay directly to the and treatment. I authorize my insurance carrier to pay directly
doctor any benefits otherwise payable to me. to the doctor any benefits otherwise payable to me.

Janet Scott
Signature of patient (or parent of minor child)
Signature of patient (or parent of minor child)

Physician signature: Donald Milford MD

SSN: 300-03-0303
EIN 66-6000600
Participating Provider for: TRICARE, CHAMPVA, Country Group and Blue Cross

DateofService 8/20/XX
Diagnosis Procedure Charge
99214 Office Visit, Est. Patient $85.00

Today’s Charge $85.00

Cash/Check $20.00
Balance $65.00

27-18 0205502LB03A-27-13
ICD-9-CM Coding—From Diseases of the Skin to Conditions in the Perinatal Period

Name: Janet Scott

DOB: November 11, 1985
Date of Service: August 20, 20XX

HISTORY OF PRESENT ILLNESS

The patient is white female who presents for a checkup.

PAST HISTORY
Medications: Methotrexate 2.5 mg 5 weekly, Fosamax 70 mg weekly, folic acid daily,
amitriptyline 15 mg daily, Synthroid 0.088 mg daily, calcium 2 in the morning and 2 at noon,
multivitamin daily, baby aspirin daily and Colace 1-3 b.i.d.
Illnesses: Reactive airway disease; rheumatoid arthritis; gravida 4, para 5, with one set of
twins, all vaginal deliveries; iron-deficiency anemia; osteoporosis; and hypothyroidism.
Operations: Recent surgery on her hands and feet.
ALLERGIES: NONE.
Social history: She is married. Denies tobacco, alcohol and drug use.
Family history: Unremarkable.

REVIEW OF SYSTEMS
HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic,
constitutional and psychiatric are all negative except for HPI.

PHYSICAL EXAMINATION
GENERAL: She is a well-developed, well-nourished white female in no acute distress.
VITAL SIGNS: Weight: 146. Pulse: 80. Blood pressure: 100/64. Respiratory rate: 16.
Temperature: 97.7 °F.
HEENT: Grossly within normal limits.
NECK: Supple. No lymphadenopathy. No thyromegaly.
CHEST: Clear to auscultation bilaterally. Heart: Regular rate and rhythm. Breasts: No nipple
discharge. No lumps or masses palpated. No dimpling of the skin. No axillary lymph nodes
palpated. Self-breast exam discussed and encouraged.
ABDOMEN: Positive bowel sounds, soft and nontender. No hepatosplenomegaly.
PELVIC: Normal female genitalia. Atrophic vaginal mucosa. No cervical lesions. No
cervical motion tenderness. No adnexal tenderness or masses palpated.
RECTAL: Normal sphincter tone. No stool present in the vault. No rectal masses palpated.
EXTREMITIES: No cyanosis, clubbing or edema. She does have obvious rheumatoid
arthritis of her hands.
NEUROLOGIC: Grossly intact.

ASSESSMENT AND PLAN

1. Hypothyroidism. We will recheck TSH to make sure she is on the right amount of
medication at this time, making adjustments as needed.
2. Rheumatoid arthritis. Continue her methotrexate, and she will follow up as needed.
3. Osteoporosis. It is time for her to have a repeat DEXA at this time, and that will
be scheduled.

0205502LB03A-27-13 27-19
Medical Coding and Billing Specialist

1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
M F
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
Self Spouse Child Other

CITY STATE 8. PATIENT STATUS CITY STATE

Single Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
Employed
Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State) b. EMPLOYER’S NAME OR SCHOOL NAME
M F YES NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED DATE SIGNED

14. DATE OF CURRENT ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
INJURY (Accident) OR GIVE FIRST DATE
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

17b. NPI FROM TO

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. . 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
FROM TO PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
YES NO $ $ $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 33. BILLING PROVIDER INFO & PH #
DEGREES OR CREDENTIALS (I certify that the statements on the 32. SERVICE FACILITY LOCATION INFORMATION
reverse apply to this bill and are made a part thereof.)

SIGNED DATE a. b. a. b.

27-20 0205502LB03A-27-13
ICD-9-CM Coding—From Diseases of the Skin to Conditions in the Perinatal Period

 Step 8 Review Practice Exercise 27-2

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 9 Congenital Anomalies (740-759)

 Chapter 14 of the Tabular List includes a variety of anomalies, and the conditions
are not broken down into sections. We will discuss only some of the conditions
included in this chapter. As you read through the material, remember that you
should be able to determine by the documentation in the medical record whether
the condition is congenital or acquired. Congenital anomalies are those conditions
that exist at birth, such as abnormal mental or physical traits, and other anomalies,
malformations or diseases. Such anomalies may be either hereditary or the result of
an influence that occurs during gestation, up to the moment of birth.

Spina bifida is a herniation, or abnormal bulging, of the membranes that surround

the spinal cord. This condition may cause an excess accumulation of spinal fluid
within the ventricles, known as hydrocephalus. When you use code category 741,
indicate the region of the unfused vertebral bone with the fifth-digit subclassification.

Glaucoma and cataract can be congenital anomalies of the eye. Congenital,

newborn, or infantile glaucoma is an enlargement and hazing of the corneas. This
condition EXCLUDES glaucoma of childhood (365.14) and traumatic glaucoma due
to birth injury (767.8). The term congenital cataract is for common, usually
bilateral opacities present at birth. This condition EXCLUDES infantile cataracts
(366.00-366.09).

Let’s code a capsular cataract found in a newborn. First, locate the problem in the
Index to Diseases. The problem, Cataract, is the main term. The condition is found
in a newborn, meaning it is a congenital anomaly. The subterm congenital is next
in the coding pathway, followed by capsular. Following this route, you find that the
tentative code is 743.31. Then, turn to the Tabular List to determine the highest level
of specificity, and you’ll confirm that code 743.31 Congenital anomalies of eye,
Congenital cataract and lens anomalies, Capsular and subcapsular cataract
is correct.

Code category 744 Congenital anomalies of ear, face and neck contains a list of
exclusions that you should be aware of when you code from it. Conditions included
in the codes for anomalies of the ear that cause impairment of hearing vary from
absence of the auditory canal to absence of the entire ear. Deafness without mention
of cause and indicates that codes in the range of 389.0 through 389.9 are more
appropriate. In subcategory 744.2, you will find codes for other specified anomalies
of the ear that do not cause impairment of hearing. These conditions include the
absence of an ear lobe, absence of the eustachian tube and bat ear.

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Medical Coding and Billing Specialist

Some ears stick out more than normal, which can be referred to as bat ear. Although
correcting this condition is not medically necessary, some people choose to do so
because of self-esteem issues. To code this condition, simply locate Bat ear in the
Index to Diseases and you find code 744.29. Determine the highest level of specificity
in the Tabular List. This confirms code 744.29 Congenital anomalies of ear, face,
and neck, Other specified anomalies of ear, Other is the accurate code.

In code group 745 Bulbus cordis anomalies and anomalies of cardiac septal
closure, you will find conditions such as aortic and ventricular septal defects. A
combination of cardiac defects pulmonary stenosis, interventricular septal defect,
dextroposition of the aorta and right ventricular hypertrophy is termed tetralogy of
Fallot. This condition EXCLUDES Fallot’s triad, which you would code as 746.09
Anomalies of pulmonary valve, Other. To code tetralogy of Fallot, use Fallot’s as
the main term to locate in the Index to Diseases. Locating the subterm tetrad or
tetralogy provides you with the tentative code of 745.2. An alternative pathway
would be Tetralogy of Fallot that also provides the tentative code of 745.2. Now turn
to the Tabular List to determine the highest level of specificity. If you find 745.2
Bulbus cordis anomalies and anomalies of cardiac septal closure, Tetralogy
of Fallot, you have the correct code. Great job!

A cleft palate is a congenital fissure of the soft palate alone, or of both the soft
palate and the hard palate. The cleft typically opens through the roof of the mouth
into the nasal cavity, and extends anteriorly to the premaxilla, where it deviates to
the right or left, following the line of fusion. A cleft lip is the separation of two sides
of the lip. Conditions in category 749 are cleft palate, cleft lip and cleft palate with
cleft lip. The conditions are further classified as unilateral or bilateral, and complete
or incomplete. Unilateral refers to one side, while bilateral indicates that the cleft
occurs on both sides. When the cleft involves a small portion of either the palate or
the lip, it is termed incomplete. A complete separation of both the anterior bony
hard palate and the posterior fleshy soft palate is termed complete.

The group of codes for congenital anomalies of the genital organs EXCLUDES
syndromes associated with anomalies in the number and form of chromosomes
(codes 758.0 through 758.9). Female organs affected by such anomalies include the
ovaries, fallopian tubes, uterus, cervix, vagina and external female genitalia. Male
organs of this category include the testicles and penis. Pseudohermaphroditism is
the presence of gonads of one sex and external genitalia of the other sex.

Code category 754 Certain congenital musculoskeletal deformities INCLUDES

deformities that are nonteratogenic (not a product of congenital anomalies) but
that are considered to be the result of intrauterine malposition and pressure. The
sites affected by these conditions include the face, spine, hip, leg and feet. Code
category 755 Other congenital anomalies of limbs EXCLUDES those deformities
that are classifiable to codes 754.0 through 754.8. Code group 755 is specific to the
upper and lower limbs.

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ICD-9-CM Coding—From Diseases of the Skin to Conditions in the Perinatal Period

Now let’s code a deformed finger of a newborn. Again, the term newborn indicates
this is a congenital deformity. In the Index to Diseases, use the coding pathway
of Deformity, finger, congenital. Determine the highest level of specificity of the
tentative code of 755.50 in the Tabular List. You find 755.50 Other congenital
anomalies of limbs, Other anomalies of upper limb, including shoulder
girdle, Unspecified anomaly of upper limb. “Anomalies of upper limb” applies,
because the finger is part of the upper limb. “Unspecified anomaly” applies, because
the type of deformity is not noted. You have the correct code.

Code group 757 Congenital anomalies of the integument INCLUDES

anomalies of the skin, subcutaneous tissue, hair, nails and breast. The category
EXCLUDES hemangioma (228.00 through 228.09) and pigmented nevus (216.0
through 216.9). Birthmarks are included in this category. A benign tumor of blood
vessels due to malformed angioblastic tissue is termed a birthmark, strawberry
nevus, port-wine stain or vascular hamartomas. Albinism is not included as a
congenital skin condition because it is a disorder of the amino-acid metabolism.

Category 758 Chromosomal anomalies INCLUDES syndromes associated with

anomalies related to the number and form of chromosomes. You are to use additional
codes for conditions associated with the chromosomal anomaly. Down syndrome,
or Trisomy 21, is usually caused by an extra copy of the twenty-first chromosome.
Characteristics of Down syndrome include a smaller-than-normal and abnormally
shaped head, a flattened nose, protruding tongue and upwardly slanted eyes. The
hands of individuals with Down syndrome are short and broad, and their fingers are
short, as well. Their mental and social skills also are delayed. Although the severity
of intellectual disabilities vary, it usually is moderate to severe in persons with
Down syndrome. The average life span is shortened for people with this condition
because of increased episodes of congenital heart disease.

The final code category of this chapter is 759 Other and unspecified congenital
anomalies. This group of codes consists of absence of the spleen, adrenal gland or
parathyroid gland; conjoined twins; and Marfan syndrome. Marfan syndrome is a
connective-tissue multisystemic disorder. The disorder is characterized by skeletal
changes and cardiovascular defects. Skeletal changes include having a tall, lanky
body with long limbs and spider-like fingers. Curvature of the spine, or scoliosis,
is common with Marfan syndrome, as well. Defects of the cardiovascular system
might include enlargement of the base of the aorta, aortic regurgitation, mitral valve
prolapse and dissecting aortic aneurysms. Since there is not just one treatment for
this condition, the characteristics of Marfan syndrome should be addressed as needed.

The following is a cardiology consultation report for you to read through. Take
your time and review the details so you have a good sense of the patient’s condition
and the diagnoses. Then, when you’re ready, determine the correct diagnosis code
or codes based on this report. Figure out the coding pathway(s), determine the
tentative code(s) from the Index to Diseases, and then confirm the accuracy of your
conclusions in the Tabular List. When you’re done, compare the process you went
through and the final code results with our summary that follows the report.

0205502LB03A-27-13 27-23
Medical Coding and Billing Specialist

CARDIOLOGY CONSULTATION REPORT

REASON FOR REFERRAL
Severe chest pain.
HISTORY OF PRESENT ILLNESS
This is a 24-year-old white male with Marfan’s syndrome diagnosed 11 years ago and
since then complains of intermittent severe chest pain. He was admitted yesterday
after 10 hours of sharp, substernal chest pain, radiating to the neck, back, left arm,
and left leg. No history of nausea, vomiting, shortness of breath, or diaphoresis. Over
the past several years, the pain has been increasing in intensity. Exertion will almost
always bring it on, although it also occurs at rest and with anxiety. He was started on
Isordil, then diltiazem 1 year ago with initial improvement, now not effective. Inderal
was started with uncertain efficacy. Over the past 5-6 years, he has 10-block dyspnea
on exertion and chest pain. He was previously followed at another institution. His
last hospitalization was 5 months ago. At that time, echocardiography showed no
mitral regurgitation, positive mitral valve prolapse, and tricuspid valve prolapse with
4+ tricuspid regurgitation. The patient states he has had MVP and stated he had a
global decrease in left ventricular function. The prior hospitalization had a negative
aortogram to look for aortic dissection. A chest x-ray at that time was also negative.
The patient has a history of staphylococcal endocarditis. Cardiac catheterization
done at that time showed pulmonary artery stenosis.
PAST MEDICAL HISTORY
Medications: Diltiazem 30 mg t.i.d., Inderal 20 mg b.i.d., nitroglycerin, Motrin.
Illnesses: Marfan’s syndrome, chronic diarrhea, possible malabsorption syndrome for 1 year.
Operations: Exploratory laparotomy 2 years prior to the admission for appendectomy
and removal of Meckel’s diverticulum.
ALLERGIES: THE PATIENT IS ALLERGIC TO PENICILLIN WITH HISTORY OF RASH.
Social history: No history of alcohol or tobacco use.
Family history: Incidences of sudden death in grandparents and mother. He
has a brother with Marfan’s and a maternal grandmother with Crohn’s disease.
REVIEW OF SYSTEMS
Otherwise noncontributory.
PHYSICAL EXAMINATION
GENERAL: The patient is alert and comfortable and in no distress.
VITAL SIGNS: Pulse: 60/min. Respiratory rate: 18/min. Blood pressure: 88/60.
Temperature: 98.4 °F.
SKIN: Nondiaphoretic.
HEENT: PERRLA. Normocephalic, atraumatic. Funduscopic examination normal. EOMs
intact. Tympanic membranes clear.
NECK: Supple without JVD or carotid bruits.
CHEST: Heart: Regular rate and rhythm with distant heart tones. Normal S1, S2 without
gallops or murmurs. There is a 1+ midsystolic click when patient is turned to 30 degrees.
ABDOMEN: There is a well-healed scar in the midline of the lower abdomen. Normal
bowel sounds, nontender, no hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema. Slender body habitus.

27-24 0205502LB03A-27-13
ICD-9-CM Coding—From Diseases of the Skin to Conditions in the Perinatal Period

DATABASE
Chest x-ray: Slender cardiac silhouette. EKG has a sinus rhythm of 71/min with
an incomplete right bundle branch block. This study is unchanged from a prior
electrocardiogram of 1 month ago. Chest CT: Aneurysm present without evidence
of dissection.
ASSESSMENT AND RECOMMENDATIONS
1. Recurrent severe chest pain attributed to mitral valve prolapse, increasing in
frequency and intensity. History of global poor left ventricular function. Cannot rule
out cardiomyopathy. Suggest that Inderal and Isordil be discontinued. Increase
diltiazem to 60 mg t.i.d. and continue to increase diltiazem as symptoms necessitate.
2. The EKG suggests the presence of septal defect. Will schedule 2D Doppler
echocardiogram with flow study.
3. Marfan’s syndrome with aortic aneurysm without evidence of dissection.

This coding example has several parts, so we’ll review them one part at a time.

1. You note in the assessment and plan for this patient that mitral valve prolapse
is causing the chest pains, which is the reason for this encounter. So the first
coding pathway is Prolapse, mitral valve. Following this pathway in the Index to
Diseases, you identify a tentative code of 424.0. When you look up this code in the
Tabular List, you find 424.0 Other diseases of endocardium, Mitral valve
disorders to be accurate.
2. The next primary problem to address is the aortic aneurysm, for which you identify
a coding pathway of Aneurysm, aorta. Following that pathway in the Index to
Diseases, you find a tentative code of 441.9, which you then check to determine the
highest level of specificity in the Tabular List. Based on the information you find
there, you choose 441.9 Aortic aneurysm of unspecified site without mention
of rupture as the correct code for this portion of the diagnosis.
3. Now you must find the correct code for the diagnosis of Marfan syndrome. Follow a
coding pathway of Syndrome, Marfan’s in the Index to Diseases, and you will come
up with a tentative code of 759.82. You could also have found the same tentative
code if you had chosen the alternative pathway of Marfan’s, syndrome. Once
again, check the Tabular List to determine the highest level of specificity. You
can comfortably conclude that code 759.82 Other and unspecified congenital
anomalies, Other specified anomalies, Marfan syndrome is correct.
Finally, you are ready to assign diagnosis codes 424.0 441.9 759.82 to this
consultation report.

We’re now about two-thirds of the way through this lesson, and it’s time to stop
and review what you’ve read and practiced in this section to see how well you
understand it. Complete the following Practice Exercise before you learn about
the next chapter of the Tabular List.

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 Step 10 Practice Exercise 27-3

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Spina bifida of L3-L4

ICD-9-CM code: _______________________________

2. Simple hypoplasia of the right eye

ICD-9-CM code: _______________________________

3. Infant born with absence of external auditory canal

ICD-9-CM code: _______________________________

4. Roger’s disease
ICD-9-CM code: _______________________________

5. Fallot’s triad
ICD-9-CM code: _______________________________

6. Single umbilical artery of a newborn

ICD-9-CM code: _______________________________

7. Congenital honeycomb lung

ICD-9-CM code: _______________________________

8. Unilateral cheilopalatoschisis, incomplete

ICD-9-CM code: _______________________________

9. Didelphic uterus
ICD-9-CM code: _______________________________

10. Coding Challenge

CONSULTATION REPORT

REASON FOR REFERRAL

Noted to have left low-set ear, left string-like thumb attached to metacarpal and left
clubfoot following breech cesarean section.

HISTORY OF PRESENT ILLNESS

The patient is a 1-day-old male infant born to a gravida 1 mother by a crash
cesarean section for double footling breech with multiple congenital anomalies.

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PHYSICAL EXAMINATION
GENERAL: Weight: 2500 gm. Length: 45 cm. Head circumference: 34.5 cm.
HEENT: Head: Normocephalic. Anterior fontanelle small but open. Eyes: Mild
mongoloid slant and hypertelorism (IC 2.5 cm). Ears: Left auricle small and
crumpled appearance. External auditory canal appears patent. Mouth: Palate high
and arched.
NECK: Very short and posterior, hairline appears low.
CHEST: No deformity. Nipples well formed. Heart: PMI on the left. Lungs: Clear.
ABDOMEN: No organomegaly. Liver on the right. Umbilical cord stump dry.
GENITALIA: Normal male with descended testes.
RECTAL: Patent.
EXTREMITIES: Left hand with hypoplastic thumb which is attached by a piece of
skin. Left forearm has mesomelia but not camptomelia. Right hand with proximally
placed thumb.
NEUROLOGIC: Good cry and muscle tone.

DATA BASE
X-rays reveal multiple cervical spine anomalies characterized by hypoplasia including
hemiatrophy of T1, butterfly pattern of T3, and left rib anomalies. Chest film also
shows evidence of congenital heart disease, patent ductus arteriosus, and possible
ventricular septal defect. Chest x-ray and abdominal films show no evidence of situs
inversus. Stomach bubble on the left and heart on the left, liver on the right.

ASSESSMENT
Multiple congenital anomalies. Congenital anomalies found in this infant so far are:
1. Dysplasia of the left auricle.
2. Multiple vertebral anomalies in the cervical and upper thoracic spine.
3. Left thumb hypoplasia.
4. Mesomelia (abnormally short) left forearm without camptomelia.
5. Congenital heart disease.
6. Ear anomalies and cervical spine anomalies are seen in Goldenhar’s syndrome
(oculoauriculovertebral dysplasia). Vertebral anomalies and congenital heart
disease are seen in VACTERL association. Both conditions are thought to occur as
sporadic events during embryonic and fetal development. There is increased risk for
other abnormalities such as renal and gastrointestinal malformations. Intellectual
disabilities is not a constant feature but is increased in Goldenhar’s, especially in
those with cerebral hemisphere involvement.

RECOMMENDATIONS
WCC. Intracranial sonography to rule out CNS malformation. Renal sonography,
UGI and barium enema for evaluation of the urogenital and gastrointestinal tracts.

ICD-9-CM code: _________________________________

ICD-9-CM code: _________________________________
ICD-9-CM code: _________________________________
ICD-9-CM code: _________________________________
ICD-9-CM code: _________________________________

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 Step 11 Review Practice Exercise 27-3

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 12 Certain Conditions Originating in the

Perinatal Period (760-779)
 Chapter 15 of the Tabular List contains codes that pertain to the mortality and
morbidity of the fetus or newborn. Conditions that occur during, or pertaining to, the
periods before, during or through the 28th day after birth are included in this range
of codes. This chapter INCLUDES conditions that have their origin in the perinatal
period, even if death or morbidity occurs later. You are directed to use an additional
code or codes to further specify the conditions in this chapter. The chapter is divided
into two sections: “Maternal Causes of Perinatal Morbidity and Mortality” and
“Other Conditions Originating in the Perinatal Period.”

Maternal Causes of Perinatal Morbidity and Mortality

(760-763)
This section consists of maternal conditions or complications that affect the fetus
or newborn to cause morbidity (disease) or mortality (death) to the fetus or
newborn. These conditions can be coded only if they are in fact affecting the fetus or
newborn—not just because the conditions exist. You will use the codes in this group
to code for the newborn record. These codes are used as a secondary diagnosis for the
codes that indicate liveborn infants according to the type of birth. Remember when
you coded the outcome of delivery in addition to the delivery code for the mother’s
records? When coding the baby’s record, you will always assign a code from category
V30 through V39, according to the type of birth. This code represents the principal
diagnosis, and you can assign it only once, at the time of birth.

Category 760 Fetus or newborn affected by maternal conditions which may

be unrelated to present pregnancy INCLUDES the listed maternal conditions
only when they are specified as a cause of morbidity or mortality of the fetus or
newborn. The code group EXCLUDES maternal endocrine and metabolic disorders
that affect the fetus or newborn. You are directed to code these conditions from codes
775.0 through 775.9. Category 760 conditions include hypertensive disorders,
infections, injuries and noxious influences.

Remember coding 642.33 for the diagnosis of pregnancy-induced hypertension,

undelivered-fetus example in a previous lesson? We assigned that code to the
mother’s records. If the baby’s health or life is affected by this condition during the
perinatal period, you will assign code 760.0 to the newborn’s records. We will revisit
this guideline in a later example.

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When the fetus or newborn is affected by noxious substances transmitted via the
placenta or breast milk, you will find the condition of the fetus or newborn in
subcategory 760.7. This subcategory EXCLUDES anesthetic and analgesic drugs
administered during labor and delivery (763.5), and drug withdrawal syndrome in a
newborn (779.5). Drugs and alcohol ingested by a pregnant woman pass through the
placenta to the fetus, and through the breast milk to the newborn, and so these
substances affect the health and life of the fetus or newborn. Noxious substances
include alcohol, narcotics, hallucinogenic agents, antibiotics and cocaine. Remember,
these codes apply to the newborn’s records.

Complications of the placenta, cord and membranes can affect the fetus or newborn.
When the documentation specifies a maternal condition as a cause of morbidity or
mortality in the fetus or newborn, you will code the diagnosis under category 762.

Placenta previa is the term used when the placenta develops in the lower part of
the uterus, covering the opening. Hemorrhaging in the last trimester is a common
symptom of this condition. When placenta previa affects the health and life of the
fetus, you will use code 762.0 for that condition.

The umbilical cord provides oxygen and nutrients to the fetus, and removes waste.
A prolapsed cord occurs when the cord slips into the vagina after the membranes
have ruptured and before the baby enters the birth canal. As the baby passes
through the cervix and vagina during labor and delivery, he can put pressure on the
cord, which reduces or cuts off the baby’s oxygen supply. Unless the baby is delivered
quickly, the situation could result in a stillborn delivery. The risk of prolapsed cord
is increased in breech presentations or premature deliveries.

Code category 763 Fetus or newborn affected by other complications of labor

and delivery probably seems familiar to you because we discussed many of these
complications earlier, when you studied conditions relating to pregnancy. These
conditions include breech, forceps, vacuum extraction or cesarean deliveries. When
these conditions are specified as a cause of mortality or morbidity in the fetus or
newborn, you will assign the codes to the newborn’s records.

Let’s practice applying some of this information now. You’ll code for a term newborn,
born in the hospital and delivered by cesarean section because of an abnormal fetal
heart rate during labor; the abnormal heart rate was caused by a prolapsed cord.

Once again, for the situation presented, we will go through several steps to
determine all the required codes and the correct order of those codes.

1. Based on what you have learned, you know that you must include a code
indicating liveborn infants according to the type of birth, so let’s do that first.
You choose a coding pathway of Newborn, single, born in hospital, with cesarean
delivery or section and the tentative code of V30.01 is provided. Confirm that
code with the Tabular List and you find V30.01 Single liveborn, Born in
hospital, delivered by cesarean delivery is the accurate code.

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2. Next, you will code for the abnormal fetal heart rate. The coding pathway of
Abnormal, heart, rate, newborn, during labor for the Index to Diseases gives you
a tentative code of 763.82. Then you turn to the Tabular List to review all the
information there and determine the highest level of specificity. Code 763.82
Fetus or newborn affected by other complications of labor and delivery,
Other specified complications of labor and delivery affecting fetus or
newborn, Abnormality in fetal heart rate or rhythm during labor is the
correct code for this portion of the description.
3. Then, you will code for the prolapsed cord documented in the notes. The
problem is not the presence of the cord, but that it is prolapsed. In the Index to
Diseases, locate the coding pathway of Prolapse, cord. You find a note that tells
us to see Prolapse, umbilical cord. Following the new pathway, you will choose
affecting fetus or newborn since you are coding for the newborn, not the delivery.
Determine the highest level of specificity for code 762.4 in the Tabular List. You
find that 762.4 Fetus or newborn affected by complications of placenta,
cord and membranes, Prolapse cord is correct.
4. Finally, assign the codes to the newborn’s records as V30.01 763.82 762.4.
How’d you do? If you have questions on this scenario, be sure to contact your
instructor for guidance. Now let’s move ahead where you can apply your expanding
skills to the next section of Chapter 15.

Other Conditions Originating in the Perinatal Period

(764-779)
As the title indicates, this section includes codes for other conditions that originate in
the perinatal period. In the ICD-9-CM manual and for most medical purposes, birth
weight is denoted in grams, for accuracy. Consequently, you will find a fifth-digit
subclassification box in this section, with weight ranges in grams for birth weight.
These subclassifications apply to code category 764 and to codes 765.0 through 765.1.
Codes in category 764 Slow fetal growth and fetal malnutrition are often paired
with codes in category 765 Disorders relating to short gestation and low birth
weight. The 765 category INCLUDES the listed conditions without further specification
as causes of mortality, morbidity, or additional care in the fetus or newborn. When you
specify codes 765.0 or 765.1, you will apply an additional code to indicate the weeks of
gestation. Long gestation is defined as more than 40 completed weeks to 42 completed
weeks. High birth weight is usually defined as 4,500 grams or more.

Now let’s code a scenario that includes maternal causes of perinatal morbidity
and mortality as well as causes from this section. Earlier, you learned about
pregnancy-induced hypertension, undelivered and determined the code for the mother’s
record to be 642.33. If the newborn was delivered at the hospital at 34 weeks gestation
as the result of maternal hypertension, and the hypertension was documented in the
maternal record, what ICD-9-CM codes would you assign to the newborn’s record?

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To help simplify the material, we’ll break it down into specific steps once again.

1. First, because pregnancy-induced hypertension is a condition at the time of

birth, you will need to indicate the liveborn infant according to the type of birth.
Using the coding pathway of Newborn, single, born in hospital the tentative code
V30.00 is suggested. When you check the Tabular List for this code, you find
V30.00 Single liveborn, Born in hospital, delivered without mention of
cesarean delivery is the right code for this portion of the documentation.
2. Next, you know that the baby was premature because it was delivered at 34
weeks gestation. So, start with the coding pathway of Newborn as the main term,
and find gestation as a subterm, with additional subterms under that for number
of completed weeks. The tentative code for 33-34 completed weeks is 765.27.
Now you go to the Tabular List to determine whether this is the accurate code,
and you find 765.27 Disorders relating to short gestation and low birth
weight, Weeks of gestation, 33-34 completed weeks of gestation. So we
can feel comfortable that this is the correct code.
3. Then, you need to know that a premature delivery is often associated with the
newborn’s mortality and morbidity; in this case, the premature delivery is the
result of the mother’s hypertension. Therefore, it’s logical to consider a coding
pathway that begins with Hypertension as the main term. You locate this main
term in the Hypertension table of the Index to Diseases, and then look for a
reasonable subterm within the table. Try “complicating pregnancy,” since that’s
a common description for problems related to pregnancy and childbirth, and see
where that takes you. Under complicating pregnancy, childbirth, or the puerperium,
you find fetus or newborn. The Malignant column is the only one to provide a code,
so you have a tentative code of 760.0. Now, go to the Tabular List once more, and
determine the highest level of specificity for this code to be sure you have the
correct one. You find 760.0 Fetus or newborn affected by maternal conditions
which may be unrelated to present pregnancy, Maternal hypertensive
disorders and verify you have the correct code.
4. The final step is to make sure you have all the necessary codes, and that you have
assigned them in the correct order. Based on the guidelines, you will assign codes
V30.00 765.27 760.0. Good work!
Birth trauma, hypoxia, asphyxia and respiratory distress syndrome are some other
conditions you will encounter in this section. Injury to the newborn during the
delivery is a birth trauma. Injuries might be due to vacuum extraction or breech
presentation. You will use code category 768 Intrauterine hypoxia and birth
asphyxia only when the condition is associated with a newborn morbidity classified
elsewhere. When the oxygen intake is insufficient, it causes fetal distress and
possibly death.

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Code category 771 Infections specific to the perinatal period INCLUDES

infections acquired before or during birth, or via the umbilical cord or during the first
28 days after birth. These are infections such as congenital rubella, congenital herpes
simplex, infection of the umbilical stump and thrush in a newborn. Other infection
specific to the perinatal period (771.8) requires you to use an additional code to
identify the organism for septicemia, UTI or bacteremia of a newborn.

Two prominent diseases that are included in code category 773 Hemolytic disease
of fetus or newborn, due to isoimmunization are ABO isoimmunization and
Rh isoimmunization. Blood types are composed of groups (A, B, AB, O) and types
(Rh positive and Rh negative). In most cases, the blood of the mother and fetus are
compatible. However, when there is incompatibility, the health and life of the fetus are
at risk. For ABO isoimmunization, the mother’s blood group is O, and the fetus’ blood
group is either A or B. The mother develops antibodies against this “foreign” blood, and
these antibodies cross the placenta and destroy the infant’s red blood cells. The same
destruction process occurs when the mom is Rh negative and the fetus is Rh positive,
which is known as Rh isoimmunization. The risks for the fetus include premature
delivery (before 37 weeks gestation), severe anemia at birth and excessive bilirubin
levels. Testing can be done to determine whether the Rh factor might be a problem in
the pregnancy. If so, Rh-immune globulin will be given to the mother at 28 weeks into
the pregnancy to help prevent the destruction of the red blood cells in the fetus.

Jaundice is a yellowing of the skin and the whites of the eyes caused by an
accumulation of the yellow-brown bile pigment bilirubin in the blood. In certain
subcategories for this disease, you will use an additional code to identify the cause.
You will find that neonatal jaundice is a manifestation of an underlying disease,
and so you should code the underlying disease first. In general, perinatal jaundice is
a straightforward category to code. But if you have questions, remember that your
instructors are just a phone call away!

Now it’s your turn to practice coding from this section. Read through the following
physician’s notes and then determine what code or codes you think are correct. As
usual, we’ll review the process afterward to see how well you did.

SUBJECTIVE
A 3-day-old baby is brought in by mother, presenting with fever, jaundice,
and is inconsolable. Poor weight gain is also noted. Mother has been typed
as Rh negative, while baby is Rh positive.
OBJECTIVE
Physical exam: Febrile, yellowish eyes and skin noted.
ASSESSMENT
Baby is jaundiced due to Rh antibodies still in her system.
PLAN
Baby will be hospitalized for a transfusion to completely exchange the
infant’s blood.

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Based on the notes, you start with a coding pathway of Jaundice as the main
term, which you locate in the Index to Diseases. Under the main term, you find the
subterms fetus or newborn. Looking at the subterms here, you first find due to or
associated with, Rh, antibodies provides the tentative code 773.0. You then turn
to the Tabular List to determine the highest level of specificity. You find 773.0
Hemolytic disease of fetus or newborn, due to isoimmunization, Hemolytic
disease due to Rh isoimmunization, is the correct code.

The next code group is 775 Endocrine and metabolic disturbances specific to
the fetus and newborn. This category INCLUDES transitory conditions caused by
the infant’s response to maternal endocrine and metabolic factors, the infant’s
removal from those conditions, or its adjustment to extrauterine existence. The
syndrome of “infant of a diabetic mother” is an example of conditions in this
category. This condition occurs when the maternal diabetes mellitus affects the fetus
or newborn, usually in the form of hypoglycemia. Neonatal diabetes occurs when
the infant’s sugar level is abnormally high and requires insulin to control it.

Code group 779 Other and ill-defined conditions originating in the perinatal
period includes convulsions, feeding problems, drug reactions and withdrawals
and stillbirth not elsewhere classified. Feeding problems in a newborn consist of
regurgitating, slow feeding and vomiting. An infant of a drug-dependent mother
might suffer from drug withdrawal syndrome because the fetus was exposed to the
drugs the mother has taken. A newborn experiencing drug withdrawal requires
supportive care, such as swaddling, frequent small feedings and observation until he
has stabilized from the drug withdrawal.

You’re on the home stretch of this lesson! This concludes the basic information you
need to know as you begin coding medical diagnoses and conditions in Chapters 12
through 15 of the Tabular List. Before you review the lesson and complete the Mail-in
Quiz, take a few minutes to review Step 12 and then complete the Practice Exercise to
reinforce what you have learned about codes in the 760 through 779 categories.

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 Step 13 Practice Exercise 27-4

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Premature infant was delivered by cesarean at 35 weeks’ gestation due

to fetal distress during the labor. Code the baby’s record.
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

2. Vaginal delivery of a term newborn in a hospital noted to be large for

gestational age at 4000 grams. Code the baby’s record.
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

3. Post-term vaginal delivery of liveborn infant in a hospital with Down

syndrome. Code the baby’s record.
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

4. Term vaginal delivery of newborn in a hospital, small for gestational

date, diagnosed with fetal alcohol syndrome. Code the baby’s record.
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

5. Newborn twins delivered in a hospital, premature at 32 weeks

gestation, via c-section, one stillborn. Code the baby’s record.
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

 Step 14 Review Practice Exercise 27-4

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

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 Step 15 Lesson Summary

 Once again, we’ve covered a lot of coding territory in this lesson. You’ve learned many
new terms and even more instructions and details about how to code correctly for a
wide range of diagnoses. You’ve studied conditions and diseases from the skin and
subcutaneous tissue, to the musculoskeletal system and connective tissue, and to
congenital anomalies and conditions in the perinatal period. Now that you’ve made it
this far in your study of ICD-9-CM codes, your confidence should be increasing. You
are very close to completing all of this new information about ICD-9-CM coding!

Take whatever time you need to review the content and Practice Exercises in this
lesson, and then go ahead and complete the Mail-in Quiz.

 Step 16 Mail-in Quiz 27

 Follow the steps to complete the Quiz.

a. Be sure you’ve mastered the instruction and the Practice Exercises that
this Quiz covers.
b. Mark your answers on your Quiz. Remember to check your answers with
the lesson content.
c. When you’ve finished, transfer your answers to the Scanner Answer Sheet
included. Use only blue or black ink on your Scanner Answer Sheet.
d. Important! Please fill in all information requested on your Scanner Answer
Sheet or when submitting your Quiz online.
e. Mail the Answer Sheet to the school via mail, fax or, to receive your grade
immediately, submit your answers online at www.uscareerinstitute.edu.

Mail-in Quiz 27
Choose the best answer from the choices provided. Each item is worth 2.5 points.

1. Which is a true statement of congenital anomalies? _____

a. They are conditions that exist at birth.
b. Congenital anomalies cannot be surgically repaired.
c. These are mechanical injuries.
d. Congenital and acquired anomalies are the same.

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2. Which region of the vertebral column is composed of 12 vertebrae? _____

a. Thoracic
b. Sacral
c. Lumbar
d. Cervical

3. Which is a true statement of the section 760-763, Maternal Causes of

Perinatal Morbidity and Mortality? _____
a. This group of codes is assigned to the newborn record.
b. These conditions are only coded if they are affecting the fetus, not just
because they exist.
c. This section consists of maternal conditions or complications that affect
the fetus or newborn to cause disease or death to the fetus or newborn.
d. All of the above

4. Which is not a true statement of cellulitis? _____

a. It is an acute, pus-producing inflammation.
b. Cellulitis is never found in the muscle.
c. Cellulitis may be associated with an abscess.
d. It can be a localized collection of pus.

5. In which stage of pressure ulcers does the skin blister, allowing

bacteria to enter the site? _____
a. Stage IV
b. Stage V
c. Stage II
d. Stage III

6. Which type of fracture occurs as the result of the bone structure

weakening by a pathological process? _____
a. Pathological fracture
b. Traumatic fracture
c. Spontaneous fracture
d. Both a and c

7. Which condition is not coded in subcategory 744.2? _____

a. Absence of an ear lobe
b. Absence of the auditory canal
c. Absence of the eustachian tube
d. Bat ear

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8. What are the layers of skin called? _____

a. Epidermis and dermis
b. Hair, nails and glands
c. Sebaceous, apocrine and eccrine
d. Horny, clear, granular, prickle cell and basal layers

9. _____ is a chronic, systemic disease characterized by recurrent

inflammation of the synovial joints and related structures.
a. Systemic lupus erythematosus
b. Rheumatoid arthritis
c. Joint mice
d. Degenerative joint disease

10. Which is not a true statement of jaundice? _____

a. It is a yellowing of the skin and the whites of the eyes.
b. There is no treatment for jaundice.
c. Neonatal jaundice is a manifestation of an underlying disease.
d. It is caused by an accumulation of the yellow-brown bile pigment
bilirubin in the blood.

11. Injury to the newborn during the delivery is _____.

a. a birth trauma
b. never coded
c. an unlikely event
d. none of the above

12. Which is not a true statement of Down syndrome? _____

a. Those with this condition have increased episodes of congenital heart
disease.
b. Characteristics include a flattened nose and protruding tongue.
c. It is also known as Trisomy 21.
d. The average lifespan is the same as one without Down syndrome.

13. _____ is any disease of the bone.

a. Osteomyelitis
b. Osteopathy
c. Osteoporosis
d. Osteoarthritis

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14. Which is not a condition categorized as seborrheic dermatitis? _____

a. Cradle cap
b. Dandruff
c. Diaper rash
d. Seborrheic infantile dermatitis

15. Blood types are composed of _____.

a. groups and types
b. A, B, AB and O
c. Rh positive and Rh negative
d. All of the above

16. Which is not a true statement of intervertebral discs? _____

a. They cushion the vertebrae from shock from movement.
b. Disorders of the spine always exist with disorders of the discs.
c. The discs form the major joint at each level of the spine.
d. They allow the spine to bend.

17. _____ is an acute or chronic inflammatory rash marked by itching and

redness that is a result of cutaneous contact with a specific allergen
or irritant.
a. Contact dermatitis
b. Atopic dermatitis
c. Seborrheic dermatitis
d. None of the above

18. Which is not a true statement of systemic lupus erythematosus? _____

a. You are to use an additional code to identify manifestations.
b. Lupus is a chronic inflammatory disease of the connective tissue.
c. There is a cure for SLE.
d. Characteristics of this disease include fever and weakness.

19. Which condition is influenced by age, genetics and testosterone? _____

a. Alopecia
b. Lack of hair
c. Baldness
d. All of the above

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20. Which is a noninflammatory degenerative joint disease characterized by the

repair of joint cartilage not keeping up with cartilage degeneration? _____
a. Osteomyelitis
b. Osteoporosis
c. Osteoarthritis
d. Osteopathy

Choose the best diagnostic code(s) from the choices provided. Each item is worth 2.5 points.

21. Newborn triplets delivered via c-section at the hospital at 28 weeks

gestation. The babies are small for dates but otherwise healthy. Code
for the baby’s record. _____
a. V37.01 765.24 764.0
b. V34.01 765.24 765.00
c. V37.01 765.24 764.00
d. V34.01 765.24 764.00

22. Carbuncle located on the back of the ear lobe _____

a. 680.0
b. 680.9
c. 680.8
d. 680.09

23. Old bucket handle tear of medial meniscus _____

a. 836.0
b. 891.0
c. 717.0
d. 717.41

24. Recurrent bilateral congenital hip subluxation _____

a. 718.25
b. 835.00
c. 754.33
d. 754.30

25. Staphylococcal arthritis of the forearm _____

a. 711.03 038.10
b. 711.03
c. 711.03 041.11
d. 711.03 041.10

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Medical Coding and Billing Specialist

26. Systemic sclerosis with lung involvement _____

a. 710.1
b. 710.1 517.2
c. 515
d. 710.10

27. Term newborn delivered vaginally at the hospital. Due to the baby being
exceptionally large for the gestational age at 5000 grams, his clavicle was
fractured during the delivery. Code the baby’s records. _____
a. V30.00 767.2 766.1
b. V30.00 810.00 766.0
c. V30.00 810.00 766.1
d. V30.00 767.2 766.0

28. Herniated intervertebral disc, L4-L5 _____

a. 722.10
b. 553.9
c. 553.8
d. 722.73

29. Unilateral incomplete cleft palate and cleft lip _____

a. 749.20
b. 749.22
c. 749.02 749.12
d. 749.03 749.14

30. Heat rash _____

a. 782.1
b. 691.0
c. 705.1
d. 693.0

31. Spondylolisthesis due to weightlifting _____

a. 738.4
b. 756.12
c. 721.90
d. 720.9

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32. Congenital hip dislocation _____

a. 835.00
b. 754.35
c. 754.30
d. 718.75

33. Stage I pressure ulcer located at the upper back _____

a. 707.0 707.21
b. 707.19 707.21
c. 707.9 707.21
d. 707.02 707.21

34. Late effect of fetal alcohol syndrome _____

a. 655.44
b. 760.71
c. 305.00
d. 779.89

35. A 20-year-old male with Marfan syndrome diagnosed with a dissecting

aortic aneurysm _____
a. 441.00 759.82
b. 441.9 759.82
c. 441.02 759.82
d. 441.0 759.82

36. Eczema due to detergents _____

a. 692.9
b. 692.0
c. 690.18
d. 692.4

37. Newborn found on steps of hospital is now hospitalized and diagnosed

with hypothermia _____
a. V30.1 778.3
b. V30.00 780.99
c. V30.10 778.3
d. V30.1 780.99

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Medical Coding and Billing Specialist

38. DERMATOLOGY CONSULTATION REPORT

REASON FOR REFERRAL
Referred for blisters and rash of mucous membranes and skin.

HISTORY OF PRESENT ILLNESS

Rash developed inside mouth, then “bumps” appeared under skin at various
places. Oral lesions painful after rupture.

PAST HISTORY
Habits: No smoking, drinking or drug use.
Medications: No medications.
ALLERGIES: ALLERGIC TO TETRACYCLINE.
Social history: Patient is an investigative reporter. Recent travels include Iran
and China. Has recently returned from Brazil one week before onset of symptoms.
Family history: Noncontributory.

REVIEW OF SYSTEMS
Skin: Other than HPI, no complaints.
Hair: No alopecia.
Cardiorespiratory: No murmurs, palpitations.
Gastrointestinal: No diarrhea, nausea, vomiting.
Genitourinary: No dysuria or hematuria.
Neurologic: No seizures or headaches.

PHYSICAL EXAMINATION
GENERAL: The patient is a thin, quiet 28-year-old black male in no acute distress.
VITAL SIGNS: Pulse: 66, regular. Blood pressure: 122/78. Respiratory rate: 20,
regular. Temperature: 99.4 °F.
HEENT: Head: Normocephalic. Eyes: EOMs intact. Funduscopic examination
normal. Ears: Tympanic membranes clear. Nose: Mucous membranes clear. Mouth:
Multiple tense and flaccid bullae scattered throughout the buccal mucosa and
pharyngeal mucosa. There are interspersed areas of erosion.
NECK: Supple. No adenopathy.
CHEST: Clear to auscultation and percussion.
ABDOMEN: Soft and flat. No organomegaly or inguinal adenopathy.
GENITALIA: Normal male genitalia. Testicles descended.
RECTAL: No prostate enlargement. Stool guaiac negative. No blood on the
examining glove.
EXTREMITIES: Multiple ruptured bullae in various stages are seen, from raw and
denuded to crusted.
NEUROLOGIC: DTRs normoreflexive. Cranial nerves 2-12 are intact.

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DATABASE
CBC normal. Chest film clear. Skin biopsy shows suprabasal epidermal cell separation.

ASSESSMENT
Pemphigus. Rule out toxic epidermal necrolysis, bullous contact dermatitis and
erythema multiforme.

RECOMMENDATIONS
Review skin biopsy and immunofluorescence test. Begin prednisone 60 mg daily
until diagnosis confirmed. If new lesions still appear after 5 days, consider
hospitalization and use of immunosuppressive medications.
a. 782.1 709.8
b. 782.1 709.8 694.4
c. 694.4
d. 694.4 782.1

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Medical Coding and Billing Specialist

39. OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS
Cervical spondylosis myelopathy.

POSTOPERATIVE DIAGNOSIS
Cervical spondylosis myelopathy.

PRIMARY PROCEDURE
C3-C7 LAMINECTOMY.

SECONDARY PROCEDURE
SECTIONING OF BILATERAL C3-C6 DENTATE LIGAMENTS.

ANESTHESIA
General endotracheal, administered by anesthesiologist.

PROCEDURE
The patient was taken to the operating room and placed in a supine position.
After endotracheal intubation and induction of general anesthesia, the patient
had a precordial Doppler monitoring system placed, as well as a central venous
catheter. He was then placed in a sitting position with Mayfleld three-point pin
headrest fixed to the table. The patient’s head was kept in a neutral position due
to the significant anterior compressive disease in his spine, and the posterior
portion of the head was shaved. The head and neck were prepped and draped
in the usual fashion. A midline incision was then marked out from the external
occipital protuberance down to the T1 spinous process, and the subperiosteal
area over the lamina from C3-C7 bilaterally was infiltrated with 0.5% Xylocaine
containing 1:100,000 epinephrine. The incision was then carried down through the
skin and subcutaneous tissues, and self-retaining retractors were placed, while
sharp dissection was used to carry out the dissection down to the spinous processes
from C2-C7. Unipolar cautery and periosteal elevators were used to elevate the
paraspinous muscles off the spinous processes and off the lamina bilaterally from
the inferior aspect of C2-C7, and self-retaining retractors were put into place. The
spinous processes were then removed with a spine cutter, and a high-speed drill
was used then to fashion a trough bilaterally from C3-C7 at the lateral aspect of the
lamina. This was done bilaterally, and then a small Kerrison was used to slightly
widen and complete the bony trough down to the ligamentum flavum. Then the
lamina segments from C3-C7 were dissected off as a unit from the ligamentum
flavum with sharp dissection.

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ICD-9-CM Coding—From Diseases of the Skin to Conditions in the Perinatal Period

The laminectomy was then widened somewhat to complete it with a small Kerrison
rongeur, and the dura was then pulsating nicely. The dura was then opened in
the midline with sharp dissection, and under the operating microscope, the C3-C6
dentate ligaments bilaterally were sectioned, using microinstrumentation. There
did seem to be some posterior displacement of the cord after this, and it seemed to
ride a bit more freely. The dura was then closed with a running 4-0 nylon suture,
and Gelfoam was placed over the dural opening. The wound was irrigated copiously
with Ringer’s lactate containing bacitraci, and the muscle was closed in layers
with 2-0 Vicryl as was the subcutaneous tissue. Staples were used for the skin
edges. Local dressing was applied, and the patient was taken out of the Mayfield
pin headrest and placed in the supine position, extubated, and then taken to the
Neurosurgical Intensive Care Unit. Sponge and needle counts were correct.
a. 756.19
b. 756.11
c. 721.91
d. 721.1

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40. RHEUMATOLOGY CONSULTATION REPORT

HISTORY

REASON FOR REFERRAL

Evaluation for status of rheumatoid arthritis.

HISTORY OF PRESENT ILLNESS

The patient is a Caucasian female. The patient has had long-standing rheumatoid
arthritis for over 20 years, treated with various medications whose names she
cannot recall, and states that her joints are not particularly worse than one month
ago. She says there is morning stiffness that has increased somewhat during
the last five weeks. There is no acute flare-up of joint pain. The right and left
knee joints and the right ankle and foot borders bother her the most. She also
complains of subluxation of the metacarpophalangeal joints for many years. Denies
temporomandibular tenderness or difficulty swallowing. Denies skin rashes.

PAST HISTORY
Medications: Motrin 800 mg p.o. t.i.d., prednisone 20 mg p.o. b.i.d., aspirin daily
of unknown amounts, chlorpromazine 10 mg p.o. t.i.d.
Operations: Foot surgery years ago for deformity. Appendectomy and
cholecystectomy. ALLERGIES: NONE.
Family history: The father died at age 65 of pulmonary carcinoma. Mother died
at age 48 of uterine cancer. She also had diabetes.

PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure: 150/90, which is reported as elevated by the patient.
HEENT: PERRLA. Sclerae clear. Thyroid not enlarged. No adenopathy.
CHEST: Heart: Regular rate and rhythm without murmurs. Lungs: Clear.
ABDOMEN: Soft, protuberant, normal bowel sounds.
EXTREMITIES: No clubbing, cyanosis, or edema. Mostly MCP joint
involvement of both hands and MTP involvement of right foot. There are
proximal interphalangeal and MCP, MTP subluxations with overlapping toes
of the right foot. There is decreased range of motion in the ankles, wrists and
digits. Relatively good range of function of elbows, shoulders and sacroiliac
joints. No joint swelling or erythema at the present time.

ASSESSMENT
Rheumatoid arthritis with multiple joint involvement, stable. With current
conditions, hypertension may develop.

RECOMMENDATIONS
ANA, RF and thyroid panel to document rheumatoid arthritis. Bone survey.
Taper steroids to 10 mg p.o. daily. Begin Feldene for symptomatic relief. Patient
to track blood pressure readings 3x/week for three weeks and report readings
to physician.
a. 716.99 401.9
b. 714.09
c. 714.0
d. 714.09 401.9

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Congratulations!
You have completed Lesson 27.

Drive
Terrific
n t !
Quality h me
l i s
o mp
A c c Learn
ing
Skillful

Do not wait to receive the results of your Quiz

before you move on.

0205502LB03A-27-13 27-47
Medical Coding and Billing Specialist

27-48 0205502LB03A-27-13
 Lesson 28

Introduction to
ICD-9-CM
Medical Coding—
Terminology:
From Symptoms
Word Parts
to Complications
 Step 1 Learning Objectives for Lesson 28
 When you have completed the instruction in this lesson, you will be trained to do the following:
 Define and describe condition symptoms, signs and ill-defined
medical conditions.

 Explain the basic exclusions, inclusions and rules related to Chapters 16

and 17 of the ICD-9-CM manual’s Tabular List.

 Identify the diagnoses, outline the coding pathway and assign the final
code for documented disorders and diseases.

 Step 2 Lesson Preview

 In this lesson, you will learn the details of coding conditions that are included in
ICD-9-CM codes 780 through 999. In particular, the code groups in Chapters 16 and
17 of the Tabular List focus on symptoms, signs and ill-defined conditions; and on
injury and poisoning.

As you’ve experienced in recent lessons, this lesson consists of varied and important
details that you need to understand to become a proficient and accurate medical coding
and billing specialist. Focus carefully as you work through the material, take plenty of
breaks to refresh your mind and always remember that your instructor is available to
assist you if you are uncertain about any of the information or how to find the correct
codes. So let’s get started on these last chapters of the ICD-9-CM manual.

0205502LB03A-28-13
Medical Coding and Billing Specialist

To help make sure you don’t get confused as you code the practice
exercises and scenarios throughout the following ICD-9-CM coding
lesson, it’s important to keep in mind that we are focusing for now only
on ICD-9-CM codes—not CPT codes. You will see physician notes and
documentation about specific procedures in some of the scenarios we
use just because we want you to practice with authentic examples. But
remember that you will code only the diagnoses during these lessons—
you’ll have plenty of time and lots of practice combining procedural and
diagnostic codes in later lessons, after you’ve become more familiar and
comfortable with the ICD-9-CM codes.

 Step 3 Symptoms, Signs, and Ill-Defined Conditions

(780-799)
 When no other diagnosis code quite fits the condition identified in the physician’s
documentation, you will turn to this chapter, Chapter 16 in the ICD-9-CM manual,
which contains symptoms, signs and ill-defined conditions, to assist you. Review the
notes provided at the beginning of the chapter to understand when it is appropriate
to use these codes. As we introduce this portion of the manual to you, we will discuss
both general symptoms and symptoms associated with specific body systems. We
also will define and discuss nonspecific abnormal findings. Now let’s take a look at
the section that focuses on codes for symptoms of diseases and other conditions.

Symptoms (780-789)
A symptom is defined as any evidence of a disease or
disorder (such as pain) that is discovered. When a positive
diagnosis is not or cannot be provided, you will code
the symptom or symptoms of the presenting problem.
In Lesson 23, we discussed unconfirmed diagnoses,
or uncertain conditions. When the physician’s final
diagnosis is an unconfirmed diagnosis, you will look
to the symptoms for the correct code.

General symptoms include alteration of consciousness,

hallucinations, syncope and collapse, convulsions,
dizziness and giddiness, sleep disturbances, fever, malaise A symptom is defined as any
and fatigue, generalized hyperhidrosis and other general evidence of a disease or disorder
symptoms. Let’s look at each of these conditions so that (such as pain) that is discovered.
you have a good understanding of this category.

Consciousness is a state of being aware of self and surroundings and knowing

what you are doing and intend to do. Alteration of this state can range from
drowsiness to a state of unconsciousness, known as a coma, from which a patient
cannot be awakened.

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 ICD-9-CM Coding—From Symptoms to Complications

For various reasons, a person might hear, taste, smell or feel a stimulus that is not
there. When one has a perception of an object or event when no such stimulus or
situation is present, the condition is known as a hallucination. The hallucinations
referenced in code group 780.1 EXCLUDES those associated with mental disorders,
organic brain syndromes and visual hallucinations.

Syncope is a sudden, temporary suspension of consciousness due to a reduced blood

flow to the brain. This condition is often referred to as a blackout or fainting.
Code 780.2 EXCLUDES syncope related to the carotid sinus and the heart and to
neurocirculatory asthenia, orthostatic hypotension and shock.

Sudden, involuntary contractions of the muscles are termed convulsions. Code

group 780.3 for convulsions EXCLUDES epileptic convulsions and convulsions in
newborns. Febrile convulsions, or seizures, code 780.31, are those associated
with high fever and that occur in infants and children. Other convulsions, under
code 780.39, include seizures, fits and convulsive disorders not otherwise specified.
To code a febrile seizure, two coding pathways will provide the same tentative
code. Febrile, seizure, or Seizure, febrile each provides 780.31 as the tentative code.
When you then turn to the Tabular List to determine the highest level of specificity,
you will confirm that code 780.31 General symptoms, Convulsions, Febrile
convulsions (simple), unspecified is the accurate code.

A sensation of unsteadiness with a feeling of movement might be called dizziness,

giddiness, light-headedness or vertigo not otherwise specified. The experience might
be a whirling sensation in the head, with a feeling of falling. This subcategory, 780.4,
EXCLUDES Meniere’s disease and other specified vertiginous syndromes.

Sleep disturbances consist of insomnia, sleep apnea,

hypersomnia and other dysfunctions associated with sleep
stages or arousal from sleep. Insomnia is the inability to sleep
during the period when sleep should normally occur. Sleep
apnea is the periodic absence of spontaneous breathing while
sleeping. Hypersomnia occurs when a person has excessively
long sleep cycles, but is still tired and requires naps. These
sleep disturbances can also be found in conjunction with other
disorders. For example, let’s code insomnia with sleep apnea.
Turn in the Index to Diseases to the main term Insomnia. You
will locate a code for insomnia alone, but look to the subterm
with sleep apnea, unspecified and you will see the tentative When the body
code of 780.51. Now turn to the Tabular List to determine temperature is elevated
the highest level of specificity. The code 780.51 General above normal, the
symptoms, Sleep disturbances, Insomnia with sleep condition is called a
apnea, unspecified is correct for the diagnosis. fever or pyrexia.

When the body temperature is elevated above normal, the condition

is called a fever or pyrexia. When the cause of the fever is
unknown or not otherwise specified, you will use code 780.60.

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Medical Coding and Billing Specialist

Malaise is a vague feeling of physical discomfort or lack of good health. Fatigue

results from overwork or lack of sleep, resulting in weariness, irritability and
boredom. A persistent fatigue, with symptoms of weak muscles, sore throat, tender
lymph nodes, headaches, depression and mild fever is known as chronic
fatigue syndrome. There is no known cause for this condition,
and treatment is focused on the symptoms. To code chronic fatigue
syndrome, locate the main term Syndrome in the Index to Diseases.
Using fatigue, chronic as the subterms, you will find the tentative code
of 780.71. Then turn to the Tabular List to determine the highest level of
specificity. Based on the information there, you will confirm code 780.71
General symptoms, Malaise and fatigue, Chronic fatigues
syndrome as accurate.

Hyperhidrosis is excessive sweating. The sweat appears as

droplets on the skin. Code 780.8 EXCLUDES focal hyperhidrosis
and Frey’s syndrome. Let’s say that in the dictation, instead of the
medical term hyperhidrosis, just “excessive sweating” is provided,
and you are to code that condition. Again, two coding pathways will
Hyperhidrosis is lead you to the same code. Excessive, sweating or Sweat, excessive
excessive sweating. each direct you to see also Hyperhidrosis and the tentative code
of 780.8 is provided. Once you determine the highest level of
specificity in the Tabular List, you will assign 780.8 General
symptoms, Generalized hyperhidrosis as the correct code.

Other general symptoms in code group 780.9 EXCLUDES hypothermia that is

due to anesthesia, accidental or of newborns. Code group 780.9 also EXCLUDES
memory disturbances as part of a pattern of a mental disorder. This subcategory
includes fussy infants, excessive crying of infants, memory loss, the premature
feeling of being full and generalized pain.

Now it’s your turn to practice coding this scenario of a patient who was treated in
the emergency department.

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SUBJECTIVE
Altered transient confusion and general weakness without tremors or
involuntary movement. Gait normal.
OBJECTIVE
Appearance and affect are appropriate. Level of consciousness normal.
Speech grossly intact. Oriented to time, place, person and purpose. Remote
and recent memory intact. Attention span normal. Calculating ability normal.
Abstract thinking normal. Cranial nerves:
I: Sense of smell intact.
II: Visual acuity normal. Visual fields intact at confrontation. Optic nerve
normal at funduscopic examination.
III, IV and VI: Pupil size normal. PERRLA. Extraocular movements/muscles intact.
V: Facial sensation intact. Masseter muscle strength normal.
VII: Facial symmetry and muscle strength normal.
VIII: Hearing acuity is normal bilaterally. Normal Weber test, does not
determine lateralized sound. Air and bone conductivity intact.
IX, X: Palate elevates in the midline. Gag reflex is normal. Uvula is midline.
XI: Trapezius and stemocleidomastoid strength 5/5.
XII: No tongue fasciculations, deviation or weakness.
Sensory examination: Pinprick, position and vibratory sensation normal.
Meningeal examination: Neck supple, no Brudzinski or Kernig signs present.
Motor function: Motor strength and tone decreased in the involved
extremities. No tremor or involuntary movements or fasciculations are seen.
Gait is normal. No muscle atrophy.
Cerebellar testing: Finger-to-nose and heel-to-shin testing normal. RAM
normal. No intention tremor, nystagmus. Biceps, triceps, patellar and Achilles
tendon reflexes are 2+ and equal bilaterally. Babinski’s reflex is negative.
ASSESSMENT
The findings are most likely consistent with transient ischemic attack [TIA].
Cannot exclude meningitis, multiple sclerosis, peripheral neuropathy,
arteriovenous malformation, Takayasu’s disease, subclavian steal syndrome,
neurosyphilis or focal seizures.
PLAN
Emergency CT scan and spinal tap with cell count, VDRL and culture.

In coding this outpatient scenario, you cannot code the TIA because it is unconfirmed.
The terms “most likely” and “consistent with” indicate that the physician is not certain
of the TIA diagnosis. The physician lists many other possible causes but does not
provide a definite diagnosis. In this situation, you should then look at the examination
section to see whether the physician confirms a diagnosis area. However, the exam
does not offer a definite diagnosis. Next, look to the presenting symptoms that brought
the patient in for care. The patient complains of altered transient confusion and
general weakness. Based on all this information, you will first code the transient
confusion by turning to Alteration, altered in the Index to Diseases.

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Medical Coding and Billing Specialist

The subterms awareness, transient, or consciousness, transient each provide a

tentative code of 780.02 for this condition. Next, turn to the Tabular List to determine
the highest level of specificity. Now you will code the general weakness. The coding
pathway Weak, weakness (generalized) provides 780.79 as the tentative code.
Determine the highest level of specificity and the accuracy of this code in the Tabular
List. Finally, for this scenario, you will assign code 780.02 General symptoms,
Alteration of consciousness, Transient alteration of awareness and code
780.79 General symptoms, Malaise and fatigue, Other malaise and fatigue as
the accurate codes based on these notes.

Now we’re ready to discuss symptoms that involve specific body systems. The
diagnoses that cover these symptoms and conditions include codes 781 through 789.
As in previous lessons, we will highlight some of the codes, but you should read the
category carefully whenever you are coding. There are many inclusions, exclusions
and additional notes to be aware of with the symptoms and conditions included
when coding in these codes. As always, if you have questions or concerns about the
information provided, be sure to call your instructor for assistance.

Symptoms Involving Nervous and Musculoskeletal

Systems (781)
This code category EXCLUDES depression, specific disorders relating to the back,
hearing, joint, limb, neck and vision, as well as pain in a limb. You will find codes
for symptoms such as disturbances of the sensations of smell and taste, clubbing of
the fingers and facial weakness in this category. Anosmia is the loss of the sense of
smell usually due to intranasal or neurologic diseases. A distortion of the sense of
taste, or bad taste in the mouth, is termed parageusia. A distortion of the sense of
smell, especially the smelling of odors that do not exist, is called parosmia. You will
assign code 781.1 for these three sensory disturbances.

Thickening and broadening of the tips of the fingers with increased curving of the
nails is termed clubbing of the fingers. You will often see clubbing of fingers listed
as a symptom of another disease or disorder. If the disease is unconfirmed, you will
code clubbing of fingers as the symptom, which is code 781.5.

Code 781.94 for facial weakness, or facial droop, EXCLUDES facial weakness that
is due to the late effect of cerebrovascular accidents (438.83). Facial weakness
might be a symptom of a number of conditions, including Bell’s palsy, Lyme disease,
Myasthenia Gravis, Primary Lateral Sclerosis and TIA.

Symptoms Involving the Skin and Other

Integumentary Tissue (782)
Symptoms involving skin and other integumentary tissue, found in code category
782, EXCLUDES symptoms that relate to the breast. This category consists of a
variety of skin conditions, from rash to excessive blushing. A rash, or exanthem,
is a general term for a skin eruption. Edema is an excessive amount of watery fluid
in cells, tissues or serous cavities. The edema included in this code group does not
include ascites, fluid retention, hydrothorax or nutritional edema.

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You learned about jaundice in a newborn in a previous lesson. When jaundice other
than that of a newborn occurs, you will code 782.4 for the condition. Finally, pallor
or excessive paleness (782.61) and flushing or excessive blushing (782.62) are also
included in this code category.

Now let’s try coding a symptom that involves the skin.

SUBJECTIVE
A 5-year-old female presenting with a rash on her arm and legs and
complaining of itching skin.
OBJECTIVE
Examination of skin is inconsistent with chickenpox.
ASSESSMENT
Rash.
PLAN
Patient is to treat the rash with hydrocortisone as needed for the itching.

The physician does not provide a definite diagnosis for the condition, so you will code for
the rash. To do so, first locate Rash in the Index to Diseases, where you will see code
782.1 indicated as the tentative code. Then turn to the Tabular List to determine
the highest level of specificity. Based on what you find there, you will assign 782.1
Symptoms involving skin and other integumentary tissue, Rash and other
nonspecific skin eruptions as the accurate code for this scenario.

Symptoms Concerning Nutrition,

Metabolism, and Development (783)
Symptoms that concern nutrition, metabolism and
development include anorexia, abnormal gain or loss
of weight and failure to thrive in children or adults.
Anorexia is usually a temporary loss of appetite due
to an emotional upset or illness with a fever. This
condition EXCLUDES anorexia nervosa (307.1) and
loss of appetite of nonorganic origin (307.59). Abnormal
weight gain EXCLUDES excessive weight gain in
pregnancy (646.1) and obesity (278.00) or morbid obesity
(278.01). When an acute or chronic illness interferes with
nutritional intake, absorption, metabolism, excretion and
energy requirements, the condition is known as organic
failure to thrive. This condition is not a symptom of
neglect or abuse. Failure to thrive is categorized separately for Organic failure to thrive
childhood development (783.41) and for adults (783.7). is not a symptom of
neglect or abuse.

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Symptoms Involving Head and Neck (784)

Symptoms that involve the head and neck, included within code category 784,
range from headache and throat pain to nosebleeds. Subcategory 784.0 includes
headache, facial pain and pain in the head not otherwise specified. This group of codes
EXCLUDES atypical face pain, migraines and tension headaches. Code 784.1
Throat pain EXCLUDES dysphagia (difficulty swallowing), neck pain and a sore
throat. The correct code for a hemorrhage from the nose, epistaxis, or simply a
nosebleed, is 784.7.

Symptoms Involving the Cardiovascular System (785)

Code category 785 contains codes for symptoms that involve the cardiovascular system.
Conditions included in this category include tachycardia, palpitations and septic shock.
Tachycardia is a rapid beating of the heart, conventionally applied to heart rates
greater than 100 beats per minute. This code group EXCLUDES neonatal tachycardia
(779.82) and paroxysmal tachycardia (427.0-427.2). Awareness of one’s own heartbeat,
whether it appears unusually rapid or irregular is called palpitations.

Septic shock is a serious, abnormal condition that usually affects the very old or
the very young. Septic shock occurs when an overwhelming infection of bacteria
causes a release of toxins, which results in low blood pressure and low blood flow.
Septic shock can occur only when severe sepsis is present. Therefore, if septic
shock is documented, it is necessary to code first the initiating systemic infection
or trauma, and then code 995.92 (severe sepsis), followed by code 785.52 Septic
shock. Now let’s code this condition from the following scenario.

SUBJECTIVE
An 82-year-old male arrives in the emergency department by ambulance,
complaining of chills and a fever for the last week. His wife notes he has had
shortness of breath, dizziness and confusion during this time as well. He has
had decreased urine output for the past 2 days.

OBJECTIVE
A comprehensive physical exam is performed. Extremities are cool to the
touch. Palpitations noted. Blood gas reveals low oxygen saturation and
respiratory alkalosis. Blood tests confirm kidney failure. Blood cultures, EKG
and chest x-ray are pending.

ASSESSMENT
Patient has septic shock due to a massive infection, with evidence of acute
kidney failure.

PLAN
Patient is admitted to ICU by his primary care provider.

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 ICD-9-CM Coding—From Symptoms to Complications

Based on the dictation, you will code the acute renal failure and the septic shock.
First, you will locate the code for the diagnosis of the acute kidney failure because
it is causing the systemic infection. Using the coding pathway Failure, kidney you
are directed to see Failure, renal. The new pathway Failure, renal, acute provides
the tentative code 584.9. Then, locate the coding pathway Shock, septic in the Index
to Diseases. Turn to the Tabular List to determine the highest level of specificity
for code 785.52. The notes you will find under code 785.52 direct you to code first
the systemic inflammatory response syndrome due to infectious process with organ
dysfunction (995.92). The code you need is provided in the notes, and you will
assign code 995.92. Finally, assign the diagnostic codes in the correct order: the
systemic infection, the systemic inflammatory response syndrome and the septic
shock. You will assign 584.9 Acute renal failure, unspecified, 995.92 Systemic
inflammatory response syndrome (SIRS), Severe sepsis and 785.52 Shock
without mention of trauma, Septic shock to this emergency department visit.

Symptoms Involving Respiratory System and Other

Chest Symptoms (786)
Symptoms that involve the respiratory system and other chest symptoms include
apnea, shortness of breath, wheezing, cough and chest pain. We discussed apnea
before as a general symptom of sleep disturbances. Apnea is a temporary stopping
of breathing. When this condition is not associated with the sleep process, you will
use code 786.03 for it. Shortness of breath, or SOB, has been a symptom of many
of the scenarios we have presented in the ICD-9-CM lessons. When this inability
to take in sufficient oxygen has no diagnosed cause, you will assign code 786.05 as
the symptom that involves the respiratory system. Wheezing is a symptom that
EXCLUDES asthma (493.00-493.92). To wheeze is to breathe with a high-pitched
or whistle-like sound caused by the narrowing of airways. This condition may be
due to asthma, croup, emphysema, hay fever, edema or pleural effusion. As with
the other symptoms in this chapter, if the disease is undiagnosed, you will code
wheezing instead. A cough (code group 786.2) is another common symptom of many
diseases. This code subcategory EXCLUDES psychogenic and smokers’ cough, as
well as a cough with hemorrhage.

Chest pain consists of several subclassifications to further explain the type of chest
pain. 786.50 Chest pain, unspecified is a common code when further classification
is not noted. Precordial pain, code 786.51, is chest pain over the heart and the
lower thorax. The location, or “precordial,” must be documented to use this specific
code. You will code pleurodynia, pleuritic and anterior chest wall pain with code
786.52 Painful respiration. This condition EXCLUDES epidemic pleurodynia
(074.1). Code 786.59 Other refers to discomfort, pressure and tightness in the chest.
This code group EXCLUDES pain in the breast, for which you are directed to use
code 611.71 instead. Always keep in mind that proper use of the Index to Diseases
will assist you in determining the correct code for the documented circumstance.

0205502LB03A-28-13 28-9
Medical Coding and Billing Specialist

Symptoms Involving Digestive System (787)

Code category 787 consists of symptoms that involve the digestive system, which include
symptoms such as nausea and vomiting, dysphagia, gas and diarrhea. Codes in the
nausea and vomiting (also referred to as emesis) code group, list several EXCLUDES
that you should take note of when you code from this section. These symptoms
have subclassifications to fully describe the condition. You might code nausea with
vomiting, nausea alone or vomiting alone. Dysphagia is the medical term to describe
difficulty in swallowing. You will use code 787.2  for this condition, with the fifth
digit identifying the phase of the dysphagia.

Symptoms Involving Urinary System (788)

Symptoms that involve the urinary system, which you will find in code category 788, include
codes for dysuria, urinary incontinence and urgency of urination. Codes in this category
EXCLUDES hematuria (599.70-599.72), nonspecific findings on examination of the
urine (791.0-791.9), small kidney of unknown cause (589.0-589.9), uremia NOS (586)
and urinary obstruction (599.60, 599.69). Dysuria is difficult or painful urination,
which often indicates a UTI (urinary tract infection). Urinary incontinence is
the inability to control the passage of urine from the bladder. This incontinence
can range from post-void discharge to continuous, involuntary urine seepage. For
conditions in this code group, you are directed, if applicable, to code first any causal
conditions, such as congenital ureterocele (753.23), genital prolapse (618.00-618.9)
or hyperplasia of prostate (600.0-600.9). Code 788.32 Stress incontinence, male
EXCLUDES stress incontinence relating to females, for which you will use code
625.6. Note that urge incontinence, with a code of 788.31, is the inability to
control urination upon the urge to urinate, while urgency of urination, with a
code of 788.63, consists of the urge to urinate without the lack of control.

Other Symptoms Involving Abdomen and Pelvis (789)

Other symptoms involving the abdomen and pelvis, in code category 789,
EXCLUDES symptoms that are referable to the genital organs. A fifth-digit
subclassification applies to codes 789.0, 789.3, 789.4 and 789.6. The fifth digit
specifies the abdominal site of the pain, swelling, mass, lump, rigidity or tenderness.

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 ICD-9-CM Coding—From Symptoms to Complications

The following fifth-digit

subclassification is to be
used for codes 789.0,
789.3, 789.4, 789.6:
0 unspecified site
1 right upper quadrant umbilical
2 left upper quadrant region
3 right lower quadrant
4 left lower quadrant
5 perimbilic
6 epigastric
7 generalized
9 other specified site
Multiple sites Figure
Figure 18-1:
28-1: Fourabdominal
Four Abdominal quadrants
Quadrants

When you are coding symptoms that fit within this code group, it is important to
know the acronyms that might be used to identify one of the four main quadrants.

RUQ Right Upper Quadrant

LUQ Left Upper Quadrant

RLQ Right Lower Quadrant

LLQ Left Lower Quadrant

Are you ready for more coding practice? Great! Look carefully at the diagnostic
radiology report and see how quickly and accurately you can code the diagnosis.

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Medical Coding and Billing Specialist

CT ABDOMINAL SCAN WITH CONTRAST

CLINICAL HISTORY
RLQ abdominal pain.
TECHNIQUE
Spiral abdominopelvic CT with oral and intravenous contrast material.
FINDINGS
There is mild thickening of the wall of the terminal ileum. There is an
increased number of normal sized mesenteric lymph nodes in the right
lower quadrant of the abdomen. The appendix is visualized and is
unremarkable. There is a trace amount of free fluid in the pelvis. No renal,
hepatic, splenic, or pancreatic abnormalities are seen. Renal uptake
of contrast material is prompt and symmetric. There is no evidence of
hydronephrosis. The bladder is unremarkable.
IMPRESSION
Constellation of findings consistent with ileitis, which may be due to
an infectious process or inflammatory bowel disease. No CT evidence
of appendicitis.

Let’s go over the details of this example together now. The impression notes
the findings are consistent with ileitis. However, consistent with indicates an
unconfirmed diagnosis. You’ll code the symptom documented, which is abdominal
pain. As you review the documentation, you note that the abdominal pain is located
in the right lower quadrant, and the findings verify that location, as well. First,
turn in the Index to Diseases to Pain, abdominal, and you find the tentative code of
789.0  . Now, use the Tabular List to determine the highest level of specificity of
this code. To specify the right lower quadrant, you’ll apply 3 as the final (fifth) digit.
You assigned 789.03 Abdominal pain, right lower quadrant for this diagnostic
radiology report.

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 ICD-9-CM Coding—From Symptoms to Complications

Did you get the same result? Congratulations! This completes our review of the
first section and code groups of Chapter 16. Let’s move on to the next section!

Nonspecific Abnormal Findings (790-796)

This section of Chapter 16 of the ICD-9-CM manual includes codes for nonspecific
abnormal findings based upon the examination of blood, urine and other body
substances; upon the radiological and other examination of body structure; and upon
function, immunological findings and nonspecific abnormal findings. You will use
these codes when the notes indicate that lab, x-ray, pathology and other diagnostic
studies reveal abnormal findings, and the physician documents the clinical
significance of these findings. It is also used when no definite diagnosis can be made,
and the documentation indicates that additional work up is needed.

For example, let’s say a woman has a routine mammogram. The radiologist reviews
the results, notes abnormal mammogram and requests that the patient be contacted
to have a second mammogram. To code for the radiologist, you will use the coding
pathway Abnormal, mammogram to locate the tentative code of 793.80. Then,
turning to the Tabular List, you will confirm that 793.80 Abnormal mammogram,
unspecified is the accurate code.

We’re moving right along with the material in this lesson—only one more section to
complete our introduction to the basic codes in Chapter 16 of the Tabular List!

Ill-Defined and Unknown Causes of Morbidity and

Mortality (797-799)
The final section in this chapter contains codes for conditions that pertain
to ill-defined and unknown causes of morbidity and mortality. These
conditions include senility, sudden death with an unknown cause and other
ill-defined and unknown causes of morbidity and mortality. In code category
797, “Senility without mention of psychosis” is also known as old age. This
category EXCLUDES senile psychoses (290.0-290.9). Some examples of
sudden death with cause unknown are sudden infant death syndrome (SIDS),
instantaneous death, death without signs of disease and unattended death.
Other ill-defined and unknown causes of disease conditions of a fatal outcome
are asphyxia, respiratory arrest and wasting disease.

0205502LB03A-28-13 28-13
Medical Coding and Billing Specialist

Now it’s time to test your skills in coding symptoms, signs and ill-defined conditions
with a Practice Exercise.

 Step 4 Practice Exercise 28-1

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Persistent vegetative state

ICD-9-CM code: _______________________________

2. Hypersomnia with sleep apnea

ICD-9-CM code: _______________________________

3. Pyrexia of unknown origin

ICD-9-CM code: _______________________________

4. Lethargy
ICD-9-CM code: _______________________________

5. Transient monoplegia
ICD-9-CM code: _______________________________

6. Numbness in hands
ICD-9-CM code: _______________________________

7. Chest discomfort
ICD-9-CM code: _______________________________

8. Elevated blood-pressure reading

ICD-9-CM code: _______________________________

9. Abnormal pap smear of the cervix

ICD-9-CM code: _______________________________

28-14 0205502LB03A-28-13
 ICD-9-CM Coding—From Symptoms to Complications

Use the following information to complete the CMS-1500 that follows.

10. ICD-9-CM Coding/Billing Challenge

Clinton Fangman, MD Stewart Center for Women Provider of Blue Cross

NPI: 010203321 1200 Carol Lane NPI: 0220332233
Yourtown, CO 80000 EIN: 99-9009009
Carolyn Hooper, MD (970) 555-1010
NPI: 0188123456 
 
Scott Ludwig, MD 
NPI: 0199654321 

Patient Information
Name Sally Tucker Date of Birth 11-26-60
Address 1801 Peterson Court Sex female Marital Status married
City Springtown State CO
ZIP 80002
Home Phone (970) 555-3255

Employment Information
Name of Employer Allied Professions
Occupation
If Minor, Name of School

Insurance Information
Primary Insurance Secondary Insurance
Name Blue Cross of Iowa Name Mutual Life
ID# 321 00 1010 ID# 402 00 4679
Group# BA1503 Group# LA4832
Address PO Box 1677 Address PO Box 911
City Sioux City City Denver
State IA ZIP 51102 State CO ZIP 80111
Primary Insured Name Sally Secondary Insured Name Gregory Tucker
DOB 11-26-60 DOB 9-2-61
Relation to Patient self Relation to Patient spouse
Employer Allied Professions Employer Lakeside Auto
I authorize the release of any information including diagnosis I authorize the release of any information including diagnosis and
and treatment. I authorize my insurance carrier to pay directly to treatment. I authorize my insurance carrier to pay directly to the
the doctor any benefits otherwise payable to me. doctor any benefits otherwise payable to me.

Sally Tucker
Signature of patient (or parent of minor child)
Signature of patient (or parent of minor child)

Physician signature: Scott Ludwig, MD

DateofService 6/6/XX
Diagnosis Procedure Charge
99214 Office Visit, Est. Patient $85.00

Today’s Charge $85.00

Cash.Check $10.00
Balance $75.00

0205502LB03A-28-13 28-15
Medical Coding and Billing Specialist

Sally Tucker
DOB 11 26 1960
Date of Service: 6/6/20XX

SUBJECTIVE
Patient complains of pleuritic left chest pain and a low-grade
fever.

OBJECTIVE
Temperature: 101 °F. There are rales and decreased breath
sounds in both bases with auscultation predominately in the
left base. Percussion of the left lateral aspect of the thorax
demonstrates an area of consolidation at the midaxillary line
that extends from the precordium. There is a pleural rub in the
same area.

ASSESSMENT
Suspected postoperative basilar atelectasis; associated
aspiration pneumonia cannot be excluded at the present time.
Due to this being the 2nd postoperative day, pulmonary emboli
cannot be ruled out.

PLAN
Chest film to look for consolidative collapse of the lingula and
lower lobes. Encourage deep breathing and frequent use of
incentive spirometer. Arterial blood gasses. Consultation with
pulmonary medicine.

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 ICD-9-CM Coding—From Symptoms to Complications

1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
M F
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
Self Spouse Child Other

CITY STATE 8. PATIENT STATUS CITY STATE

Single Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
Employed
Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State) b. EMPLOYER’S NAME OR SCHOOL NAME
M F YES NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED DATE SIGNED

14. DATE OF CURRENT ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
INJURY (Accident) OR GIVE FIRST DATE
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

17b. NPI FROM TO

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. . 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
FROM TO PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
YES NO $ $ $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 33. BILLING PROVIDER INFO & PH #
DEGREES OR CREDENTIALS (I certify that the statements on the 32. SERVICE FACILITY LOCATION INFORMATION
reverse apply to this bill and are made a part thereof.)

SIGNED DATE a. b. a. b.

0205502LB03A-28-13 28-17
Medical Coding and Billing Specialist

 Step 5 Review Practice Exercise 28-1

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 6 Injury and Poisoning (800-999) Part 1

 Chapter 17 of the ICD-9-CM manual is one of the largest chapters of codes, and
it contains a wide variety of conditions. We will divide this chapter into two
sections for our discussion to assist you with what might otherwise seem like an
overwhelming amount of information. Remember, you do not need to memorize the
information because you will have your ICD-9-CM manual and course materials
to refer to whenever you are coding. We will discuss the inclusions, exclusions and
additional notes in the Tabular List, as usual, and we will refer you to the ICD-9-CM
manual’s Coding Guidelines section located in the front of the book. As you will
remember from earlier lessons, the Coding Guidelines provide supplementary
information to assist you in determining the accurate codes for a number of
conditions. In addition, your instructors are a telephone call away to support you as
you continue your studies.

Before we dive into the contents of this chapter, let’s

look to see what assistance the Tabular List includes
for coding from this chapter. You will note under
the heading for Chapter 17 that you are to use an
additional code for retained foreign body, if applicable,
and you are to use E codes to identify the cause and
intent of the injury or poisoning (E800-E999). E codes
classify environmental events, circumstances and
conditions as the cause of injury, poisoning and other
adverse effects. You will use E codes in conjunction
with poisonings, and we will return to this topic of
E codes classify environmental
using E codes to identify the cause and intent of
events, circumstances and conditions
the injury later. So for right now, don’t worry about
as the cause of injury, poisoning and
including the E codes for injuries just yet, but rather
other adverse effects.
focus your attention on coding the injury itself.

The Tabular List contains notes about coding injuries—specifically, multiple and
combination coding, as well as coding multiple sites of an injury. We will look closer
at these notes, as they apply, when we discuss each category. The Tabular List also
notes that you will find categories for “late effects” in codes 905 through 909.

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 ICD-9-CM Coding—From Symptoms to Complications

Fractures (800-829)
The codes in this section EXCLUDES the conditions of malunion (733.81), nonunion
(733.82), pathological or spontaneous fractures (733.10-733.19) and stress fractures
(733.93-733.95). We have discussed pathological, spontaneous and stress fractures in
a previous lesson. Here, we will discuss body parts very specifically. We also refer to
this information throughout the lesson.

A fracture is a break or rupture in a bone. Fractures are classified as “closed” or

“open,” and identified as such by the different fourth digits. If the skin is not injured,
the fracture is termed closed. If the broken bone protrudes through the skin, the
fracture is referred to as open. A fracture not indicated as closed or open is coded as
closed. To ensure proper coding, you also should be aware of other terms that might
be used to describe an open or closed fracture. Review the boxed information that
follows to keep these other terms in mind as you code.

A closed fracture might be identified by the following terms:

comminuted depressed elevated
fissured fracture NOS greenstick
impacted linear simple
slipped epiphysis spiral

An open fracture might be identified by the following terms:

compound infected missile
puncture with foreign body

Once again, when a fracture is not identified as open or closed, or by any of the above
terms, you will code to a closed fracture. You will code fractures of multiple sites to each
specific site at the level documented by the physician. If the documentation does not
provide enough information to identify each specific site, you will code from the category
that indicates multiple fractures. For more information about coding fractures, review
the Coding Guidelines in the front of your ICD-9-CM manual.

0205502LB03A-28-13 28-19
Medical Coding and Billing Specialist

Fracture of Skull (800-804)

This section provides fifth-digit subclassifications for use with the appropriate codes
in categories 800, 801, 803 and 804. Fracturing the skull can be associated with
loss of consciousness. You will use the fifth-digit subclassification for the indicated
categories to identify whether there was a loss of consciousness and, if so, the length
of the unconsciousness. The fourth-digit classifications for categories 800, 801, 803
and 804 identify whether there was a laceration and contusion; a subarachnoid,
subdural or extradural hemorrhage; an intracranial hemorrhage; and whether the
fracture was open or closed.

Let’s code a depressed fracture of the parietal bone with a subdural hemorrhage
and the patient has been unconscious for an undetermined amount of time. In
coding this diagnosis, you will first determine the main term by asking, “What’s the
problem?” The problem is the fracture. So turn in the Index to Diseases and locate
Fracture, parietal bone. This coding pathway directs you to see Fracture, skull, vault.
So the new coding pathway will be Fracture, skull, vault. When you locate these
terms, you will see that a subdural hematoma is noted, so you will continue down
the pathway Fracture, skull, vault, with, subdural hemorrhage and you have the
tentative code of 800.2  . Now turn to the Tabular List to determine the highest
level of specificity. You will see that 800.2 is correct but that you need to apply
the fifth digit. From the information you’ve been given, you know the patient was
unconscious for an unspecified duration, so the correct fifth digit is 6. The final code
you assign for the given description is 800.26 Fracture of vault of skull, Closed
with subarachnoid, subdural and extradural hemorrhage, with loss of
consciousness of unspecified duration.

Fracture of Neck and Trunk (805-809)

The vertebral column is the flexible, bony case for the
spinal cord. A fracture of the vertebral column could
likely include a spinal cord injury. You will note that
this section contains codes with and without mention
of spinal cord injury. As with the codes for diseases
and disorders of the spine, those for fractures of the
vertebral column are organized by the specific vertebra
involved. In addition, codes 805.0 through 805.1 require
a fifth-digit subclassification to indicate the specific
vertebra fractured. Be sure to select a fifth digit from
that box when coding a fractured cervical vertebra
without mention of spinal cord injury.

Figure 28-2: Vertebral column

28-20 0205502LB03A-28-13
 ICD-9-CM Coding—From Symptoms to Complications

Code category 807 Fracture of rib(s), sternum, larynx and trachea includes a
fifth-digit subclassification box for you to use to identify the number of ribs fractured
when you are applying codes 807.0 through 807.1. For example, if you are to
determine the ICD-9-CM code for a patient who fractured four ribs, you would locate
Fracture, rib(s) in the Index to Diseases and find the tentative code of 807.0  . When
you determine the highest level of specificity in the Tabular List, you will remember
that four ribs are noted, so the correct code will be 807.04 Rib(s), closed, four ribs.
Do you understand why it is to a closed fracture? Remember that if open or closed is
not specified, you code to a closed fracture.

The sternum, commonly known as the breastbone, is a long, flat bone that forms
the center part of the chest. The sternum consists of the manubrium, the body and
the xiphoid process. The upper part of the manubrium joins with the inner ends of
the two clavicles (collarbones). Attached to the sides of the manubrium and the
body are the seven pairs of costal (rib) cartilages that join the sternum to the ribs.

Parts of the pelvis that might be fractured are the acetabulum, the pubis or other
specified parts such as the ilium and the ischium. The acetabulum is the hip
socket. The rounded, upper end of the femur, known as the head of the femur, fits
into the acetabulum or hip socket.

Ribs

Sternum:
Manubrium
Body
Xiphoid process

Figure 18-4: Anterior

Figure 28-4: View of theview
Anterior Pelvic Bones
Figure 18-3: Anterior
Figure 28-3:View of the view
Anterior Rib Cage of the pelvic bones
of the rib cage

Fracture of Upper Limb (810-819)

The area of the upper limb includes the clavicle, scapula, humerus, radius and ulna.
It also includes the carpals, metacarpals and phalanges of the hand. We will discuss
each of these code groups briefly. As you review the details of each code group in
the Tabular List, notice that the fifth-digit subclassifications throughout identify
the specific anatomical site of each bone at which the fracture occurs. You will have
lots of opportunity to review your anatomy terminology when you are coding for
fractures of these bones of the upper limb! Let’s begin by identifying the bones of the
shoulder girdle and how you go about coding for fractures of this area.

0205502LB03A-28-13 28-21
Medical Coding and Billing Specialist

Code category 810 contains codes for fractures of the clavicle, commonly referred to as
the collar bone. The fifth-digit subclassifications identify the site of a fracture of the
clavicle. The site might be unspecified; at the sternal end of the clavicle where the
collar bone meets the breastbone; at the shaft, or long slender part of the clavicle; or
at the acromial end of the clavicle, which is the highest point of the shoulder.

Fractures of the scapula, or shoulder blade, are listed in code category 811. This
category also identifies the site of the fracture with a fifth-digit subclassification. The
acromion process is the highest point and outer-most projection of the shoulder
joint. It extends sideways from the scapular spine, which is the sharp ridge that
runs across the back surface of the shoulder blade and forms the acromioclavicular
joint with the clavicle. The coracoid process projects from the front surface of the
upper border of the scapula. It can be felt between the deltoid and pectoralis major
muscles, about an inch below the clavicle. The glenoid cavity or arm socket, forms a
depression where the head of the humerus bone fits.

Figure 18-5:The
Figure 28-5: The Shoulder
shoulder Girdle
girdle and Upper
and upper limb Limb

You will use code category 812 for fractures of the humerus, the bone that extends
from the shoulder to the elbow. The fourth digit identifies the location of the fracture
as the upper end, the shaft, which is the long slender part, or the lower end of the
humerus. It also specifies whether the fracture is open or closed. The fifth-digit
subclassification indicates the portion of the upper end, shaft or lower end of the
humerus that was fractured.

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Category 813 codes for fractures of the forearm. The forearm consists of the radius and
the ulna. The radius is located on the outer or thumb side of the forearm, while the ulna
is the inner and larger bone of the forearm. With the forearm, fractures can be of the radius
alone, the ulna alone or the radius with the ulna. Again, the fourth digit identifies the
fracture location as the upper end, shaft or lower end of the radius and ulna, and whether
the fracture is open or closed. You must closely examine the fifth digit in this category
because the fracture might be of the radius alone, the ulna alone or the radius with the ulna.
Monteggia’s fracture is sometimes called a parry fracture because it oftentimes occurs
when the patient has tried to stop a punch or blow with their forearm. Colles’ fracture is
a break of the lower end of the radius, in which the lower fragment is displaced posteriorly
or behind the radius. It is called a reverse Colles’ fracture if the fragment is displaced
anteriorly or in front of the radius. This type of fracture is most commonly found in people
older than age 40 and usually results from a fall with the hand outstretched to break the fall.

Now that you have some of the basic terminology and coding details in mind for these
groups of codes, it’s time to try your hand again at coding a related diagnosis. Carefully
read the following operative report and see what code or codes you come up with for the
indicated diagnosis.

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OPERATIVE INDICATIONS
This patient presents with an open Colles fracture of the left wrist following an
automobile accident. The patient was a passenger in the vehicle that was
struck by another vehicle. The patient attempted to brace herself against the
dashboard with her left hand resulting in the fracture.

PREOPERATIVE DIAGNOSIS
Open Colles fracture, left wrist.

POSTOPERATIVE DIAGNOSIS
Same.

PROCEDURE PERFORMED
OPEN REDUCTION INTERNAL FIXATION LEFT COLLES FRACTURE WITH
DEBRIDEMENT OF OPEN FRACTURE SITE.

PROCEDURE
After the attainment of adequate general anesthesia, the left upper
extremity was prepped and draped. A skin marker was used to mark the
appropriate location using the positioner on the forearm for the radius
pins. The fracture and open wound were addressed. The wound required
significant debridement of the skin and subcutaneous tissue prior to
proceeding with the repair of the fracture.

After adequate debridement, the fracture was addressed. I was able to

reduce the fracture to the appropriate anatomical position. Fixation was
obtained using a modular hand 2-0 titanium plate with 6 cortices on either
side of the fracture. Excellent stable fixation was obtained. Rotational
alignment appeared to be satisfactory.

The wound was irrigated with normal saline and closed using 3-0 Vicryl and
4-0 nylon monofilament sutures. Sterile Xeroform 4 x 4 cast padding and ace
bandage were used. The patient tolerated the procedure well and went to
the recovery room in good condition.

After you’ve determined what you think is the correct code, compare the process you
used and your results to the following summary. To code the postoperative diagnosis for
this dictation, you must determine the problem. According to the notes, the patient has
a Colles fracture. There are two routes for this code. First, open your ICD-9-CM manual
to the Index to Diseases and follow the coding pathway Fracture, Colles, open for
the tentative code of 813.51. Now try using the coding pathway of Colles fracture,
open. You find the same code! Now determine the highest level of specificity for
the tentative code 813.51 in the Tabular List. Based on the information there, you
can comfortably assign 813.51 Fracture of radius and ulna, Lower end, open,
Colles fracture for this scenario. Does that match your results? Great!

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Next, we will discuss fractures of the carpal bone(s), or wrist, (code group 814);
and of the metacarpals or the five bones of the hand that lie between the wrist
and the phalanges; and the phalanges or fingers and thumb of the hand (code
group 815). The fourth digit of each category identifies the fracture as open or
closed. Each category also has a fifth-digit subclassification to identify the location
of the fracture(s).

Figure 28-7: Bones of the hand and wrist

As noted at the beginning of this section on fractures, you will code fractures of
multiple sites to each specific site at the level documented by the physician. If the
documentation does not provide enough information to identify each specific site,
you will code from the category that indicates multiple fractures. Code category 817
applies to multiple fractures of the hand bones, including the metacarpal bone(s)
with the phalanges of the same hand. You will use code category 819 to code for
multiple fractures that involve both of the upper limbs and an upper limb with the
rib(s) and sternum. This group includes arm(s) with rib(s) or sternum, as well as any
other bones of both arms.

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Fracture of Lower Limb (820-829)

The lower limbs of the body include the femur, tibia and fibula, the ankle, the tarsal
and metatarsal bones and the phalanges of the foot.

Greater trochanter
Head
Neck Intertrochanteric crest
Lesser trochanter
Gluteal tuberosity

Femur

Linea aspera

Medial epicondyle Lateral epicondyle

Patella
Intercondylar fossa
÷
Lateral condyle
Medial condyle
Tibial tuberosity Intercondylar eminence
(tibial spines)
Tibia
Fibula Lateral condyle
Medial condyle
Head

Interosseous membrane

Anterior crest

Calcaneus
Medial malleolus Lateral malleolus

Anterior Leg Posterior Leg

Cuboid Talus
Navicular
Metatarsal Cuneiforms:
First
Phalanges: Second
Proximal Third
Middle
Distal Sesamoid bones
(accessory ossicles)

Dorsal Ankle and Foot

Figure18-8:
Figure 28-8: Dorsal
Dorsal Ankle
ankle and
and foot
Foot
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The femur is the long bone of the thigh that extends from the pelvis to the knee.
The femur is the longest and largest bone in the body. Fractures of this bone are
classified as fracture of the neck of the femur and fracture of other and unspecified
parts of the femur. Conditions that relate to the neck of the femur are in code
category 820 and are classified to the fourth digit, which identifies the fracture as
transcervical or pertrochanteric and open or closed. A fracture through the neck
of the femur is termed transcervical, where as pertrochanteric refers to a
fracture of the femur that passes through the greater trochanter. Code category 821,
Fractures of other and unspecified parts of the femur, includes the shaft or
unspecified part of the femur and the lower or distal end.

The patella, or knee cap, is the largest sesamoid bone in the body. This triangular
bone is located at the front of the joint of the knee. Category 822 simply describes a
fracture of the patella as opened or closed.

In medical terminology, the leg is the part of the lower extremity that extends from
the knee to the ankle. The leg contains two bones, the tibia and the fibula. The tibia
is the larger and weight-bearing bone in the leg. The fifth-digit subclassification of
code category 823 identifies whether the fracture consists of the tibia alone, the fibula
alone, or the fibula with the tibia. Again, the fourth digit identifies the upper end,
shaft or unspecified part of the leg. It also describes the fracture as open or closed.

A fracture of the ankle, category 824, can be classified as medial or lateral malleolus,
bimalleolar, trimalleolar or unspecified. If only “ankle fracture” is specified on the
documentation you would code to 824.8 Fracture of ankle, Unspecified, closed.

Code categories 825 and 826 consist of codes that pertain to tarsal and metatarsal
bone fractures and fractures of one or more phalanges of the foot. There are seven
tarsal bones, two of the largest are the talus and the calcaneus, or heel bone.
The other tarsal bones are lined up in a row between the large tarsal bones and the
metatarsals. These bones are the navicular, first, second and third cuneiforms and
the cuboid. The metatarsal bones are five bones that form the arch of the foot. The
phalanges of the toes are named like the phalanges of the fingers.

Now, look at code categories 828 and 829. Once again, you will find multiple fractures
in these codes that involve both lower limbs, lower limb with upper limb and lower
limb(s) with rib(s) and sternum. You are to use this category only when the specific
bones are not documented. Otherwise, be sure to code each fracture separately.

Whew! That is quite a bit of information, and we have discussed much of the skeletal
system in this section of the lesson, as well. As you continue with the lesson, you can
refer to the graphics and descriptions of the skeletal system to help you understand
dislocations, sprains and strains, superficial injuries, contusions, crushing injuries
and burns. Next, we’ll give you a basic overview of the subcategory of codes you will
use for dislocations, from code 830 through 839.

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Dislocation (830-839)
A separation of two bones in a joint so they no longer touch each other, usually
caused by an injury, is called complete displacement. Displacement that leaves
the bones in partial contact is called subluxation. Dislocation of a joint is usually
accompanied by the tearing of the joint ligaments and damage to the membrane that
encases the joint. This section EXCLUDES congenital dislocations (754.0-755.8),
pathological dislocations (718.2) and recurrent dislocations (718.3). Dislocations
can be described as “closed” or “open,” and are identified as such by the fourth-digit
subdivision. An opened dislocation is complicated by a wound opening from the
surface down to the affected joint. When the joint is not penetrated by a wound, it is
a closed dislocation.

An open dislocation might be identified by the following terms:

Compound Infected With foreign body

A closed dislocation might be identified by the following terms:

Complete Dislocation NOS Partial
Simple Uncomplicated

With your knowledge of the anatomy provided in the fracture section,

understanding the various sites of dislocations should be fairly straightforward.
Some terminology review, though, will help you to code accurately.

Anterior—in front of

Posterior—in back of

Inferior— below

Lateral—farther away from the middle

Medial—closer to the middle

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Remember, the acromioclavicular joint is the joint between the acromial end of the
clavicle and the medial margin of the acromion. Let’s code a compound dislocation of the
acromioclavicular joint. Begin in the Index to Diseases with the main term Dislocation.
The subterm acromioclavicular (joint) suggests 831.04 as the tentative code.
Reading closer, though, you will note that (closed) is indicated, and a compound
dislocation is an open dislocation. So you need to continue in the Index to Diseases
until you locate Dislocation, acromioclavicular, open and you note that 831.14 is
the tentative code. The Tabular List will confirm that this code is at the highest
level of specificity. So 831.14 Dislocation of shoulder, Open dislocation,
acromioclavicular (joint) is the correct code to assign for a compound dislocation
of the acromioclavicular joint.

Moving on, we’ll now take a look at the next subcategory of codes, ranging from 840
through 848. You will use these codes for diagnoses of sprains and strains of joints
and the muscles adjacent to them.

Sprains and Strains of Joints and Adjacent Muscles

(840-848)
In this section of codes, the joint capsule, ligament, muscle or tendon might be
classified as an avulsion, hemarthrosis, laceration, rupture, sprain, strain or tear. The
codes in this group EXCLUDES laceration of the tendon in open wounds, which you
would code instead from categories 880 through 884 and 890 through 894. You will
not find fifth-digit subclassifications in this category, and there are no open or closed
distinctions. A good understanding of the body parts and of various ways strains and
sprains might be described are key to coding accurately from this category.

Intracranial Injury, Excluding Those with Skull Fracture

(850-854)
Previously, you studied intracranial hemorrhages and intracranial injuries
associated with skull fractures. This section deals with intracranial injuries
excluding those with skull fractures. Again, as you saw in the intracranial injuries
associated with skull fractures, you will use the fifth-digit subclassification for
categories 851 through 854 to identify whether there was an associated loss of
consciousness and, if so, the length of the unconsciousness.

A concussion, in code category 850, is a significant blow to the head that might
result in unconsciousness. This might be a mild concussion with a temporary loss
of consciousness, or a severe concussion, with prolonged unconsciousness and
inability to function properly. You will code a concussion with mental confusion or
disorientation, without actual loss of consciousness, as 850.0 Concussion, With
no loss of consciousness. This section EXCLUDES a concussion with cerebral
laceration or contusion (851.0-851.9), with a cerebral hemorrhage (852-853) and
head injury NOS (959.01).

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Remember learning about subarachnoid, subdural and extradural hemorrhages?

The hemorrhages in this section are those that occur as a result of an injury rather
than a cerebrovascular disease. Let’s review the location of each hemorrhage type:
The meninges are three layers of protective membranes that surround the brain and
the spinal cord. The thick dura mater forms the outermost layer, followed by the
arachnoid and the pia mater.
 The extradural is located outside the dura mater layer.

 The subdural is located between the dura mater and the

arachnoid layer.

 The subarachnoid is located between the arachnoid and the

pia mater layer.

Internal Injury of Thorax, Abdomen, and Pelvis (860-869)

This section lists many terms that INCLUDES notes to describe injuries of an
internal organ. It consists of codes that relate to injuries of the heart, lungs,
gastrointestinal tract, liver, spleen, kidneys, pelvic organs and intra-abdominal
organs. Be sure to review and become familiar with these terms. As always, there is
no need to memorize them. The fourth digit for these codes again identifies the injury
with or without mention of an open wound. Those injuries that are mentioned with
infection or a foreign body are also considered open wounds.

You will use code category 864 to code for an injury to the liver. This code group
requires a fifth-digit subclassification to further describe the injury. Review the
details of those fifth digits in the following box.

A hematoma is usually a clotted,

localized collection of blood in the organ.
It is caused by a break in the wall of a
blood vessel. A contusion is a bruise or
hemorrhage without a break in the skin.
The involvement and disruption of the
parenchyma, or the functional elements
of the liver, if it is lacerated, can be
classified as minor, moderate or major.

Codes for injury to the spleen and kidney

also require a fifth-digit subclassification
to further describe the extent of the injury.
The term capsule refers to the fibrous
tissue layer surrounding the organ, either
the spleen or the kidney. The capsule can
tear without disrupting the functional
elements of the organ, or the tear can
extend into the parenchyma.

2013 ICD-9-CM Professional for Physicians – Volumes 1 & 2, Salt Lake City, Utah: Ingenix, Inc., page 289, Volume 1

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In case you haven’t realized it, you’re at the half-way point in this lesson, and it’s
time to stop for a review of the most recent material. When you feel comfortable
that you understand this information, go ahead and complete the following Practice
Exercise to see how much you remember. When you’re done and have checked your
work, you’re ready to begin the second half of the lesson.

 Step 7 Practice Exercise 28-2

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Blow-out fracture of the orbital floor

ICD-9-CM code: _______________________________

2. Fracture of the C1-C4 with complete lesion of cord, paraplegia

ICD-9-CM code: _______________________________

3. Fracture of humerus at the lateral condyle, infected

(HINT: Review the section for descriptions of “closed” and “open” fractures)
ICD-9-CM code: _______________________________

4. Displacement of lumbar vertebra due to major trauma

ICD-9-CM code: _______________________________

5. Traumatic rupture of the interphalangeal joint of the toe

ICD-9-CM code: _______________________________

6. Subarachnoid hemorrhage with open intracranial wound following a

fall from a two-story building. Patient does not regain consciousness
before death.
ICD-9-CM code: _______________________________

7. Anterior dislocation of the humerus with a fracture of the acromial end

of the clavicle
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

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8. ICD-9-CM Coding Challenge

HISTORY OF PRESENT ILLNESS

The patient is an 88-year-old white female, household ambulator with a walker, who presents
to the emergency department this morning after incidental fall at home. The patient states that
she was on the ladder on Saturday, and she stepped down after the ladder and felt some pain in
her left hip. Subsequently fell injuring her left shoulder. It is unclear how long she was on the
floor. She was taken by EMS to hospital where she was noted radiographically to have a left
proximal humerus fracture and a nondisplaced left hip fracture. Orthopedics was consulted.
Given the nature of the injury and the unclear events, an extensive workup was performed
including a head CT and CT of the abdomen, which identified no evidence of intracranial
injury and renal calculi only. She presently is complaining of pain to the left shoulder.
She states she also has pain to the hip with motion of the leg. She denies any numbness or
paresthesias. She states prior to this, she was relatively active within her home. She does care
for her daughter who has MS. The patient denies any other injuries. Denies back pain.

PAST HISTORY
Medications: Presently: (1) Lipitor 20 mg daily. (2). Metoprolol 25 mg b.i.d. (3) Plavix 75
mg once a day. (4) Aspirin 325 mg. (5). Combivent aerosol 2 puffs twice a day. (6) Protonix
40 mg daily. (7) Fosamax 70 mg weekly. (8). Multivitamins including calcium and vitamin
D. (9) Hydrocortisone. (10) Nitroglycerin. (11). Citalopram 20 mg daily.
Illnesses: Extensive including coronary artery disease, peripheral vascular disease, status
post MI, history of COPD, diverticular disease, irritable bowel syndrome, GERD, PMR,
depressive disorder, and hypertension.
Operations: Includes a repair of a right intertrochanteric femur fracture.
ALLERGIES: (1) PENICILLIN. (2) SULFA. (3) ACE INHIBITOR.
Social history: She denies alcohol or tobacco use. She is the caretaker for her daughter who
is widowed and lives at home.
Family history: Not obtainable.

REVIEW OF SYSTEMS
Patient is hard of hearing. She also has vision problems. Denies headache syndrome.
Presently, denies chest pain or shortness of breath. She denies abdominal pain. Presently, she
has left hip pain and left shoulder pain. No urinary frequency or dysuria. No skin lesions.
She does have swelling to both lower extremities for the last several weeks. She denies
endocrinopathies. Psychiatric issues include chronic depression.

PHYSICAL EXAMINATION
GENERAL: The patient is alert and responsive.
EXTREMITIES: In the left upper extremity, there is moderate swelling and ecchymosis to
the brachial compartment. She is diffusely tender over the proximal humerus. She is unable
to actively elevate her arm due to pain. The neurovascular exam to the left upper extremity
is otherwise intact with a 1+ radial pulse. She does have chronic degenerative change to the
MP and IP joints of both hands. In the left lower extremity, the thigh compartment is supple.
She has pain with log rolling tenderness over the greater trochanter. The patient has pain
with any attempt at hip flexion passively or actively. The knee range of motion is between
5° and 60° with no point specific tenderness, no joint effusion, and an intact extensive
mechanism. She has 2-3+ bilateral pitting edema pretibially and pedally. The patient has
a weak motor response to the left lower extremity. She has a 1+ dorsalis pedis pulse. Her
sensory examination is intact plantarly and dorsally on the foot.

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DATABASE
Patient’s H&H is 13 and 38.7, white blood cell count is 6.9, and there are 198,000 platelets.
Electrolytes: Sodium 137, potassium 4.1, chloride 102. CO2 is 27, BUN is 20, and
creatinine 0.62. Urinalysis: The urine is clear yellow, 0-2 white cells, and no bacteria.
Radiographs: Left shoulder series was performed which identifies a 3-part valgus-impacted
left proximal humerus fracture with displacement of the greater tuberosity fragment,
approximately 1 cm. There is no evidence of dislocation. There was an AP pelvis as well as
left hip series, which identify a nondisplaced valgus-impacted type 1 femoral neck fracture.
There is also evidence of severe degenerative disc disease with degenerative scoliosis of the
LS spine. There is evidence of previous surgical repair of the right proximal femur with an
intact intramedullary nail.

ASSESSMENT
This is an 88-year-old household ambulator with a walker, status post fall with injuries to
left shoulder and left hip. The left shoulder fracture is a proximal humerus fracture, and the
left hip is a nondisplaced femoral neck fracture.

PLAN
I have discussed this case with the emergency room physician as well as the patient.
Patient should be admitted to medical service for medical clearance for surgery of her left
hip, which will include a percutaneous screw fixation. Since the patient is on Plavix, I
recommend that the Plavix be discontinued, and she should be placed on Lovenox 30 mg
subcutaneous daily, which may be stopped 24 hours before the procedure. She will need
cardiology clearance, which would include an echocardiogram in advance of the procedure.
I have explained the nature of the injuries to the patient, the recommended surgical
procedures, and the postoperative course and rehabilitation required thereafter. She presently
understands and agrees with the plan.

ICD-9-CM code: _______________________________

ICD-9-CM code: _______________________________

 Step 8 Review Practice Exercise 28-2

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

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 Step 9 Injury and Poisoning (800-999) Part 2

 As you complete this second half of the lesson, continue to focus carefully on all
the details provided in the notes and guidelines of the ICD-9-CM manual. Don’t
get discouraged if you find some information challenging (remember that your
instructors are there to clarify things and help you succeed). Keep in mind that
when you complete this lesson, you will be ready to apply all the knowledge and
skills you have gained to the ICD-9-CM coding practicum in the next lesson!

Open Wound (870-897)

An open wound is simply a trauma to the body in which the tissues have direct
exposure to the atmosphere. Terms used in this section of the Tabular List to
describe an open wound INCLUDES animal bite, avulsion (ripping or tearing
away of a part), cut, laceration, puncture wound and traumatic amputation. The
codes in this section EXCLUDES any burn, crushing injury, puncture of internal
organs, superficial injury and those conditions incidental to dislocation, fracture,
internal injury and intracranial injury. You will code open wounds with mention
of delayed healing, delayed treatment, foreign body or infection as “complicated.”
Finally, you are to use an additional code to identify an infection if it is specified in
the documentation. Understanding both the alternative words that describe an open
wound and when you are to code for “complicated” open wounds will help you in
coding diagnoses that pertain to this rather fairly straightforward section, which is
divided into the following three groups:

1. Open wound of head, neck and trunk (870-879)

2. Open wound of upper limb (880-887)
3. Open wound of lower limb (890-897)

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With these guidelines in mind, go ahead and work up the coding diagnosis for the
following wound repair.

SUBJECTIVE
Patient sustained a 1.2 cm forehead laceration resulting from a fall down
the stairs at home.
OBJECTIVE
Patient seen in the emergency department presenting with a wound to
the forehead and requested an evaluation. After examination of the
forehead, no foreign body was noted. The laceration was approximately
1.2 cm in length. It was felt sutures would provide the best healing for this
injury. Laceration was lavaged, anesthetized, and repaired with 6-0 nylon
monofilament sutures. An antiseptic dressing was then applied.
ASSESSMENT
Simple repair of 1.2 cm forehead laceration.
PLAN
The patient is to see his family physician within 3 days.

What coding pathway did you decide to use? The most obvious is probably
Laceration, forehead. What code do you find if you use that coding pathway?
Nothing? Go back and look again at the beginning of the Laceration section to see
what direction the notes provide. You are directed to “see also Wound, open, by site.”
When you try that coding pathway, Wound, open, forehead, the Index to Diseases
suggests 873.42 as the tentative code. Turn to the Tabular List to confirm this
suggestion and you’ll find that 873.42 Other open wound of head, Face without
mention of complication, Forehead is the right choice. Did you get the correct
code the first time? If so, that’s great! If not, be sure you understand where you got
off track before you go to the next section.

Injury to Blood Vessels (900-904)

Injuries whose codes are included in this section INCLUDES arterial hematoma,
avulsion, cut, laceration, rupture and traumatic aneurysm or fistula of blood vessels.
An injury included under these codes might be secondary to another injury, such
as a fracture or an open wound. Injuries included in this section EXCLUDES
accidental puncture or laceration of blood vessels during a medical procedure (998.2)
and any intracranial hemorrhage following an injury (851.0-854.1).

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Late Effects of Injuries, Poisonings, Toxic Effects, and Other

External Causes (905-909)
As we’ve discussed before, late effects indicate a condition that may occur at any time
after the acute injury. You will use the codes in this section to indicate conditions
that are classifiable to codes from groups 800 through 999. For example, let’s say a
patient is being seen for an ulcer on his knee. He had a traumatic amputation from
the knee down and is currently fitted with a prosthesis. The prosthesis is not fitting
well, rubbing the knee, which resulted in an ulcer. The principal diagnosis is the
ulcer on the knee. So to code this diagnosis, you will turn in the Index to Diseases to
Ulcer, knee, where you are redirected to see Ulcer, lower extremity. Following the new
pathway of Ulcer, lower extremity, knee provides you with 707.19 as the tentative
code. You then will confirm from the Tabular List that 707.19 is correct. Now, the
reason the patient has this ulcer is the ill-fitting prosthesis, which in turn exists as a
result of the amputation. So the ulcer is a late effect of the amputation. In the Index
to Diseases, locate Late, effect(s) (of), amputation, traumatic, where you will find a
tentative code of 905.9, which you then need to confirm in the Tabular List through
the usual process. In summary, for this diagnosis, you will assign code 707.19 Ulcer
of lower limbs, except decubitus, Ulcer of other part of lower limb, and code
905.9 Late effects of musculoskeletal and connective tissue injuries, Late
effect of traumatic amputation.

Superficial Injury (910-919)

Damage inflicted on the body that pertains to or is situated near the body’s surface
is considered a superficial injury. An example of a superficial injury is a scratch.
In fact, if you look up Scratch in the Index to Diseases, you are directed to see
Injury, superficial, by site. Other terms used in the ICD-9-CM manual to describe a
superficial injury include abrasion, blister, insect bite and superficial foreign body.
The fourth-digit subcategory for the codes in this section identifies these descriptive
injuries. A superficial injury EXCLUDES a burn or blister due to a burn;
contusions; a foreign body that pertains to granuloma and that was inadvertently
left in the operative wound, or is residual in soft tissue; a venomous insect bite; and
an open wound with incidental foreign body. Superficial injuries are also categorized
as with or without mention of infection. This section is further broken down into 10
categories. Be sure to always review the INCLUDES and EXCLUDES of a category
to assist you in accurate coding.

Contusion with Intact Skin Surface (920-924)

A contusion might be identified as a bruise or a hematoma. This section contains
codes for contusions without fracture or open wounds. The code categories are
organized by site. These codes EXCLUDES concussion, hemarthrosis, internal
organs and contusions that are incidental to other injury categories. When you code
contusions, be sure you are familiar with the exclusions of this section.

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Crushing Injury (925-929)

For the codes in this section, you are to use an additional code to identify any associated
injuries, such as fractures, internal injuries and intracranial injuries. Again, these codes
are categorized by anatomical sites.

For a coding example from this section, let’s say a four-year-old boy was playing on
the driveway, and his sister ran over his hand as she rode her bike. The injury was
extensive enough to break two distal phalanx and crush two metacarpal bones. To
code this injury, you will code the crushed hand as well as the broken fingers. Begin
your code search in the Index to Diseases at the main term Broken. You will not find
the subterm fingers. The problem is that the term broken is not considered a medical
term. A broken bone is a fracture. So now turn to Fracture, and under that you
will find the subterms finger(s), of one hand. You are directed to see also Fracture,
phalanx, phalanges, hand. Following the alternative pathway of Fracture, phalanx,
hand, distal provides the tentative code of 816.02. You’ll then confirm that code
based on the information in the Tabular List.

Now let’s turn to the crushing injury of the hand. The coding pathway of Crush, hand,
except for finger(s) alone (and wrist) suggests the tentative code of 927.20. Is that the
correct code? Turn to the Tabular List to read the description for code 927.20. The text
indicates a crushing injury to the wrist and hands, except for the fingers alone. Only
the fingers were broken, but the entire hand is indicated as crushed, so you do have
the correct code. So to complete your coding for the injury documented in this scenario,
you will assign code 816.02 Fracture of one or more phalanges of hand, Closed,
distal phalanx or phalanges and code 927.20 Crushing injury of upper limb,
Wrist and hand(s), except finger(s) alone, Hand(s).

Effects of Foreign Body Entering Through Orifice (930-939)

For the codes in this section, a foreign body is anything in the body that has been
introduced through its openings, such as when a person swallows an object not
ordinarily eaten or swallowed. These codes EXCLUDES foreign bodies in open
wounds or superficial injuries, residual in soft tissues and those inadvertently left in
an operative wound. Site categories included within this section are the external eye,
ear and nose. A foreign body might be inhaled into the trachea, bronchus and lung.
A swallowed foreign body might be found anywhere in the body that is involved in
the digestive tract, from the mouth to the bladder!

Burns (940-949)
The definition of the burns section INCLUDES scalding, chemical burns and burns from
electrical heating appliances, electricity, flame, hot objects, lightning and radiation. It
EXCLUDES friction burns and sunburns. You will assign codes from categories 940
through 949 for current unhealed burns. The first criterion for classifying burns is
the anatomical site.

0205502LB03A-28-13 28-37
Medical Coding and Billing Specialist

You cannot code burns using a single code. You code burns by site, by severity or
degree of burn, and by the percent of total body surface burned.

You will assign codes from categories 940 through 949 for current unhealed burns.
The first criteria, or axis, for classifying burns is the anatomical site. You should code
burns individually to the greatest extent possible. For example, if the physician’s report
indicates a person has multiple burns and of varying degrees on different areas of the
body, you will assign codes for each of the burns to the extent you can. Although there
are codes that classify multiple burns, you should assign these codes only when the
location of the burns is not documented.

For categories 941 through 946, the fourth digit designates the degree of the burn. First-
degree burns are superficial burns involving only the epidermal layer of the skin. They
are inflamed and painful, but they do not blister. Second-degree burns involve the dermal
layer of the skin. These burns do include blisters, and they are also quite painful since
the nerve endings are still intact. Third-degree burns are frequently called full-thickness
burns. They go completely through the skin, which may appear charred and black or dry
and white, depending on the burning agent. Third-degree burns are not usually painful,
since the nerve endings have been severely damaged or destroyed.

As you code burns, you will classify them according to the highest degree recorded in the
diagnostic statement. In other words, when you code, a third-degree burn takes precedence
over a second-degree burn, and a second-degree burn takes precedence over a first-degree
burn. For example, let’s practice coding for the diagnosis of first- and second-degree burns
of the upper arm. Turn to the main term Burn in the Index to Diseases. Next, find the site
of the burn, which is arm, upper. The burns are indicated to be first- and second-degree
burns, but you will code to the higher degree, so locate second degree. The tentative
code of 943.23 will be confirmed when you check it out in the Tabular List. You will
code 943.23 Burn of upper limb, except wrist and hand, Blisters, epidermal loss
[second degree], upper arm for this example. You will not code the first-degree burn
because it is at the same site as the second-degree burn.

When burns are documented at more than one site, you first sequence the code for
the site of the highest-degree burn, sequencing the additional codes for the other sites
in descending order of degree. Say you have a patient with a first-degree burn of the
forearm, with first- and second-degree burns of the upper arm. For the second-degree
burn of the upper arm in the example above, you determined that 943.23 is the
accurate code. Now, return to Burn in the Index to Diseases, and locate the subterms
forearm, first degree. Code 943.11 is the tentative code provided. Turn to the Tabular
List to confirm this code. You will sequence the highest degree burn first, so you will
assign 943.23 Burn of upper limb, except wrist and hand, Blisters, epidermal
loss [second degree], upper arm, followed by 943.11 Burn of upper limb,
except wrist and hand, Erythema [first degree], forearm.

Category 948 is used to classify burns according to the extent of the body surface area
involved. This code can be used by itself when the site of the burn is unspecified, or it is
used in conjunction with a code from 940 to 947 to further describe the patient’s condition.

28-38 0205502LB03A-28-13
 ICD-9-CM Coding—From Symptoms to Complications

Code 948 requires both a fourth digit

and a fifth digit. The fourth digit
specifies the total percent of the body
surface burned at any degree. The
fifth digit specifies the percent of
the body surface with third-degree
burns only. Code 948 could also
be used for a patient who suffered
first-degree burns to the chest wall and 8%,
second-degree burns to the abdominal ults
wall
with 11 percent of the total body surface
n.
area burned. Along with codes 942.23 and hild
942.12 showing the site and degree, you ormay
use 948.10 to show that 11 percent of the total
surface area was burned, but none of the burns Figure
Figure 28-9:
18-9: The
Therule
Ruleofofnines
Nines
were third-degree burns.

The method used to estimate burned body surface in burn patients is called the
Rule of Nines. The different areas of the body make up percentages: Head and
neck 9%, each arm 9%, anterior leg 9%, posterior leg 9%, anterior trunk 18%,
posterior trunk 18%, genitalia 1%. This rule applies to adults only and is not to be
used for children. Consult the physician caring for the child before you assign burn
percentages for children.

So let’s build on our previous example with a diagnosis of first-degree burn of the
forearm, with first- and second-degree burns of the upper arm and 4 percent of the total
body surface area is documented as burned. You’ve already determined the first two
codes to be 943.23 and 943.11. For the third code, you’ll return to the main term
Burn in the Index to Diseases, and then locate the subterm extent (percentage of
body surface). The tentative code indicated for less than 10 percent of body surface
is 948.0  . You then turn to the Tabular List to determine the highest level of
specificity. Remember that the fifth-digit subclassification pertains to third-degree
burns, which these are not. So the correct percentage code is 948.00 Burns
classified according to extent of body surface involved, Burn [any degree]
involving less than 10 percent of body surface, less than 10 percent or
unspecified (third-degree burn). You will record the final codes for this complete
diagnosis as 943.23 943.11 948.00.

2013 ICD-9-CM Professional for Physicians – Volumes 1 & 2, Salt Lake City, Utah: Ingenix, Inc., page 299, Volume 1

0205502LB03A-28-13 28-39
Medical Coding and Billing Specialist

Injury to Nerves and Spinal Cord (950-957)

This section INCLUDES codes for division of nerve, lesions in continuity, traumatic
neuroma and traumatic transient paralysis that may occur with an open wound. These
codes EXCLUDES accidental puncture or laceration during a medical procedure,
which in that circumstance you are to code to 998.2 instead. Injuries to nerves
include injuries to the optic nerve, cranial nerves, nerve roots and peripheral nerves.
Spinal cord injuries are classified by site: cervical, dorsal or thoracic, lumbar, sacral,
cauda equina, multiple or unspecified sites. Both the cervical and dorsal sites
indicate the level of the spinal cord injury.

Certain Traumatic Complications and Unspecified Injuries

(958-959)
Category 958 consists of codes for early complications of trauma. This code
group EXCLUDES adult respiratory distress syndrome, flail chest, post-
traumatic seroma, shock lung related to trauma and surgery and those that
occur during or following medical procedures. These conditions include air and
fat embolism, secondary and recurrent hemorrhage and traumatic shock.

You will use code category 959 only for unspecified injuries. If the documentation
notes an injury of the ear but doesn’t specify what type of injury, you will assign
code 959.09.

Poisoning by Drugs, Medicinal, and Biological

Substances (960-979)
Turn to the Tabular List to see what information is provided to help you accurately
code the conditions included in this section. Poisonings listed in codes 960 through
979 INCLUDES an overdose of any drug, medicinal or biological substance and
instances of the wrong substance given or taken in error. This section contains
exclusions that you should review when you are coding any poisoning by drugs,
medicinal and biological substances. Note, for example, that the section EXCLUDES
adverse effects of any correct substance properly administered. In this case, only the
code for the adverse effect and the E code are used—not the poisoning code.

The Tabular List also notes that you are to use an additional code to specify the
effects of poisoning. Remember that at the beginning of this chapter, the Tabular
List instructs you to use an E code to identify the cause and intent of the injury or
poisoning. Although we put our discussion of the E codes that pertain to injuries on
hold, we will be explaining the use of E codes in conjunction with the poisoning codes.
Remember: E codes are a Supplemental Classification of External Causes of Injury and
Poisonings. Finally, when you assign poisoning codes always sequence the poisoning
code first, followed by the manifestation code, if noted, and then the E code.

28-40 0205502LB03A-28-13
 ICD-9-CM Coding—From Symptoms to Complications

The primary goal of this portion of the lesson is to learn to use the Table of Drugs
and Chemicals accurately so you can find the correct code. Turn to the beginning of
the Table of Drugs and Chemicals, Section 2 of Volume 2. You are to use the codes
contained in this section when the documentation includes a statement of poisoning,
overdose, wrong substance given or taken or intoxication. The table headings that
pertain to external causes are defined as follows:
 Accidental poisoning—accidental overdose of a drug, the wrong drug given
or taken, or a drug unintentionally taken or administered. It is also used to
show toxic external causes of substances that are mainly nonmedicinal.

 Therapeutic use—a correct substance properly administered but that results

in an adverse effect.

 Suicide attempt—self-inflicted poisonings.

 Assault—poisoning inflicted by another person with intent to injure or kill.

 Undetermined—intent of the poisoning, whether intentional or accidental,

cannot be determined.

Let’s look at an example scenario and walk through the process of using the Table of
Drugs and Chemicals.

SUBJECTIVE
A 15-year-old female is brought into the emergency department after
accidentally taking an antihistamine drug. She is complaining of shortness
of breath.
OBJECTIVE
The physician performs a detailed physical examination.
ASSESSMENT
Poisoning from the medicine, resulting in respiratory distress.
PLAN
Use pulse oximetry to maintain SaO2 at 96% via nasal cannula. Continuous
blood pressure and pulse monitoring. Give patient 30 mL ipecac syrup
followed by 200-300 mL of water. Repeat dose one time if vomiting does not
occur in 20 minutes. Will reassess following treatment.

0205502LB03A-28-13 28-41
Medical Coding and Billing Specialist

What is the problem? Respiratory distress. So you’ll turn to the Index to

Diseases and find the coding pathway Distress, respiratory. The tentative code
of 786.09 is provided. Then, determine the highest level of specificity and
confirm that this is the accurate code based on the information provided in the
Tabular List.

Now you need to determine what drug is causing the respiratory distress. The
documentation indicates it is an antihistamine. You’ll find Antihistamine in
the Table of Drugs and Chemicals. In the first column, you’ll find the poisoning
code 963.0, and then you’ll look across the columns until you find Accident. The
corresponding code for antihistamine in the Accident column is E858.1. You can
then confirm each of these codes in the Tabular List.

To accurately sequence the codes, you list the poisoning code first, followed by the
manifestation and then the E code. You assign the codes as 963.0, 786.09 and
E858.1 for this scenario. Did you follow the process and how to determine all three
codes? If not, go back over the steps; then, if you still have questions, check with
your instructor for clarification.

Toxic Effects of Substances Chiefly Nonmedicinal As to

Source (980-989)
This section consists of codes for toxic effects that pertain to, are due to, or are of the
nature of a poison or toxin from a substance that does not have a healing quality.
Examples of such substances are mercury, mushrooms or asbestos poisonings.

Other and Unspecified Effects of External Causes

(990-995)
Conditions you will find within this section of codes are frostbite, heat stroke,
motion sickness, adverse effects not elsewhere classified and systemic inflammatory
response syndrome.

An adverse effect of a drug is when it is correctly prescribed and properly

administered but the patient suffers with a bad reaction. These adverse effects
include tachycardia, delirium, gastrointestinal hemorrhaging, vomiting, hypokalemia,
hepatitis, renal failure or respiratory failure. When you are coding an adverse effect to
proper use of medication, you will sequence the adverse effect first, followed by the E
code to identify the agent as a therapeutic use. You will not record the poisoning code.

28-42 0205502LB03A-28-13
 ICD-9-CM Coding—From Symptoms to Complications

Now it’s your turn. Code and sequence the following scenario, and then compare
your results to the summary that follows.

SUBJECTIVE
A 42-year-old male complaining of severe dizziness is seen by his family
physician. He has been taking fluoxetine for the past 2 weeks as prescribed
for his depression.
OBJECTIVE
A detailed physician examination is performed.
ASSESSMENT
The patient is having dizziness secondary to the fluoxetine hydrochloride.
PLAN
Patient is advised to discontinue use of the drug. Begin Xanax XR 0.5 mg once
daily and call in 3 days for dosage increase if necessary.

To code this scenario, you will code the dizziness as the principal diagnosis and then
the appropriate E code. Turn to the Index to Diseases and locate Dizziness, for which
you are provided the tenative code of 780.4. Using the Tabular List, determine
the highest level of specificity for that code. Now turn in the Table of Drugs and
Chemicals, and locate the drug Fluoxetine hydrochloride. Find the code provided
in the Therapeutic Use column, which is E939.0. So you will assign codes 780.4
Dizziness and giddiness and E939.0 Antidepressants, in that order, for this
example.

The ICD-9-CM manual provides code 995.2 Unspecified adverse

effect of drug, medicinal and biological substance to identify
an adverse reaction when the nature of the reaction is not specified.
You will apply a final digit to identify the substance.

Also remember that when you assign poisoning codes, you always
sequence the poisoning code first, followed by the manifestation code,
such as coma, and then the appropriate E code.

0205502LB03A-28-13 28-43
Medical Coding and Billing Specialist

Complications of Surgical and Medical Care, Not

Elsewhere Classified (996-999)
As you will see when you look at this section of codes for surgical and medical
complications, it EXCLUDES a number of conditions. Turn to the Tabular List
to review the extensive list of exclusions to this section. If the complication can be
classified elsewhere, you will not use the codes of this section. No time limit is defined
for the development of a complication. The complication might occur during the
hospital episode in which the care was provided, shortly thereafter or even years later.
When the complication occurs during the episode in which the operation or other care
was given, the complication code is assigned as a coexisting condition to the principal
diagnosis. When the complication develops later and is the reason for the visit, the
complication is designated as the principle diagnosis. Category 996 codes for any
complication peculiar to certain specified procedures. These conditions pertain to a
device, implant or graft of the cardiac, vascular, genitourinary, internal orthopedic
nature; prosthetics; transplanted organs; or reattached extremity or body parts. You
will use an additional code to identify the specified infections pertaining to internal
prosthetics. For transplanted organs, identify the nature of the complication with an
additional code.

Let’s try coding a complication of a breast prosthesis due to a Staphylococcal aureus

infection. In the Index to Diseases locate the coding pathway of Complications,
breast implant (prosthetic), infection or inflammation and you will find the tentative
code of 996.69. Turn to the Tabular List to verify this code. The beginning of 996.6
directs you to use an additional code to identify the specified infection, which is the
staphylococcus aureus. Now turn to Infection, staphylococcal, aureus in the Index
to Diseases. The tentative code 041.11 would be confirmed in the Tabular List as
well. Now you can assign 996.69 Infection and inflammation reaction due to
internal prosthetic device, implant, graft, Due to other internal prosthetic
device, implant or graft and 041.11 Staphylococcal aureus for this diagnosis.

Complications affecting specified body systems, not elsewhere classified, are coded
from category 997. You are to use an additional code to identify the complications.
The anatomical sites are provided, with inclusions, exclusions and additional notes
to assist you in accurate coding.

Postoperative shock, accidental puncture during a procedure and postoperative

infection are some conditions found in category 998. Category 999 includes codes for
air embolisms, phlebitis and infections following an infusion, injection, transfusion
or vaccination.

This concludes the first 17 chapters of the Tabular List. Let’s pause to review what
you’ve learned before wrapping up the ICD-9-CM lessons.

28-44 0205502LB03A-28-13
 ICD-9-CM Coding—From Symptoms to Complications

 Step 10 Practice Exercise 28-3

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Patient on bicycle crashed into the windshield of a parked car,

resulting in traumatic enucleation of right eyeball and multiple
lacerations of the forehead.
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

2. Laceration of the forearm, with tendon involvement

ICD-9-CM code: _______________________________

3. Compound femoral shaft fracture with femoral vein avulsion

ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

4. Blister on heel of foot due to uncomfortable shoes

ICD-9-CM code: _______________________________

5. Black eye, fractured nose and multiple facial contusions

ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

6. Compound fracture of the medial malleolus with crushing injury to

the ankle
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

7. Patient presents with 1st and 2nd degree burns of the thigh, 2nd degree
burns of the back, 13% of the body surface involved
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

8. Accidental barbiturate overdose

ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

9. Swallowed nail polish remover as a suicide attempt

ICD-9-CM code: _______________________________
ICD-9-CM code: _______________________________

0205502LB03A-28-13 28-45
Medical Coding and Billing Specialist

Use the following information to complete the CMS-1500 that follows.

10. ICD-9-CM Coding/Billing Challenge

Eric Sulliman, MD
1000 Main Street
Yourtown, CO 80000
(970) 555-1717

Patient Information
Name Steven Gibbs Date of Birth 08-10-2000
Address 1343 Oval Street Sex M Marital Status single
City Windsor State CO
ZIP 80520
Home Phone 970-555-7643

Employment Information
Name of Employer
Address
City State
ZIP
Phone
Occupation
Student Full time X Part-time If minor, name of school Windsor Public Schools

Insurance Information
Primary Insurance Secondary Insurance
Name Mountain States Name
ID# 012-34-5678 ID#
Group# 420 Group#
Address 1801 SW Vine Street Address
City Denver City
State CO ZIP 80217 State ZIP
Primary Insured Name Michael Gibbs Secondary Insured Name
Relation to Patient father Relation to Patient
DOB 2-11-1969 DOB
Employer Advanced Communications Employer
I authorize the release of any information including diagnosis and I authorize the release of any information including diagnosis
treatment. I authorize my insurance carrier to pay directly to the and treatment. I authorize my insurance carrier to pay directly
doctor any benefits otherwise payable to me. to the doctor any benefits otherwise payable to me.

Michael Gibbs
Signature of patient (or parent of minor child) Signature of patient (or parent of minor child)

Physician signature: Eric Sulliman, MD

SSN: 987-21-5432
NPI: 0377484809
Participating Provider for: All private insurance

DateofService 9/10/20XX
Diagnosis Procedure Charge
99204 New Patient, Office Service $88.00

Today’s Charge $88.00

Cash/Check $0.00
Balance $88.00

28-46 0205502LB03A-28-13
 ICD-9-CM Coding—From Symptoms to Complications

Name: Steven Gibbs

DOB: August 10, 2000
Date of Service: September 10, 20XX

CHIEF COMPLAINT
Burn, right arm.

HISTORY OF PRESENT ILLNESS

This patient had hot oil splashed onto his arm, burning from the elbow to the wrist on
the medial aspect. He has had it cooled and presents with his father to the office as a new
patient for care.

PAST HISTORY
Noncontributory.
Medications: None.
ALLERGIES: NONE.

PHYSICAL EXAMINATION
GENERAL: Well-developed, well-nourished male child who is appropriate and
cooperative. His only injury is to the right upper extremity. There are 1st- and 2nd-
degree burns on the right forearm, ranging from the elbow to the wrist. The 2nd-degree
areas with blistering are scattered through the medial aspect of the forearm. There is no
circumferential burn, and I see no areas of deeper burn. The patient moves his hands well.
Pulses are good. Circulation to the hand is fine.

DISPOSITION
Home.

ASSESSMENT
There are 1st-degree and 2nd-degree burns, right arm, secondary to hot oil spill.

PLAN
The wound is cooled and cleansed with soaking in antiseptic solution. The patient was
given Demerol 50 mg IM for pain. A burn dressing is applied with Neosporin ointment.
The patient is given Tylenol No. 3, tabs #4, to take home with him and take 1 or 2 every 4
hours p.r.n. for pain. He is to return tomorrow for a dressing change. Tetanus immunization
is up to date. Preprinted instructions are given.

0205502LB03A-28-13 28-47
Medical Coding and Billing Specialist

1500
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
M F
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
Self Spouse Child Other

CITY STATE 8. PATIENT STATUS CITY STATE

Single Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
Employed
Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State) b. EMPLOYER’S NAME OR SCHOOL NAME
M F YES NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED DATE SIGNED

14. DATE OF CURRENT ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
INJURY (Accident) OR GIVE FIRST DATE
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

17b. NPI FROM TO

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES
YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. . 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
FROM TO PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
YES NO $ $ $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 33. BILLING PROVIDER INFO & PH #
DEGREES OR CREDENTIALS (I certify that the statements on the 32. SERVICE FACILITY LOCATION INFORMATION
reverse apply to this bill and are made a part thereof.)

SIGNED DATE a. b. a. b.

28-48 0205502LB03A-28-13
 ICD-9-CM Coding—From Symptoms to Complications

 Step 11 Review Practice Exercise 28-3

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 12 Lesson Summary

 Congratulations—you’ve completed another lesson in your ICD-9-CM coding
training, and the end of your introductory journey through the coding pathways of
ICD-9-CM coding is in sight! As you are well aware, you’ve covered a tremendous
amount of information. Whenever you use the ICD-9-CM manual, both during the
remainder of this course and as you gain experience in your new profession as a
medical coding and billing specialist, you will increase your understanding and
coding skills along the way. Hopefully, though, you already have a solid sense of
what’s involved in coding medical conditions and diagnoses.

 Step 13 Mail-in Quiz 28

 Follow the steps to complete the Quiz.

a. Be sure you’ve mastered the instruction and the Practice Exercises that this
Quiz covers.
b. Mark your answers on your Quiz. Remember to check your answers with
the lesson content.
c. When you’ve finished, transfer your answers to the Scanner Answer Sheet
included. Use only blue or black ink on your Scanner Answer Sheet.
d. Important! Please fill in all information requested on your Scanner Answer
Sheet or when submitting your Quiz online.
e. Mail the Answer Sheet to the school via mail, fax or, to receive your grade
immediately, submit your answers online at www.uscareerinstitute.edu.

0205502LB03A-28-13 28-49
Medical Coding and Billing Specialist

Mail-in Quiz 28
For questions 1 through 20, choose the best answer from the choices provided.
Each item is worth 2.86 points.

1. When you assign poisoning codes, how should you sequence the
codes? _____
a. Manifestation code first, followed by the poisoning code, if noted, and
then the E code.
b. Poisoning code first, followed by the manifestation code, if noted, and
then the E code.
c. E code first, followed by the poisoning code, if noted, and then the
manifestation code.
d. Sequencing doesn’t matter.

2. Which is a true statement of septic shock? _____

a. If septic shock is documented, you will code first the initiating systemic
infection or trauma, and then to code 995.92, followed by code, 785.52.
b. Septic shock can occur only when severe sepsis is present.
c. Septic shock is a serious, abnormal condition that usually affects the
very old or the very young.
d. All of the above

3. You will code to a closed fracture when _____.

a. a fracture is not identified as open or closed
b. a foreign body is identified
c. infection is noted
d. it is described as a puncture fracture

4. Which is not part of the upper limb? _____

a. Carpals
b. Radius and ulna
c. Femur
d. Collarbone

5. A persistent fatigue, with symptoms of weak muscles, sore throat, tender

lymph nodes, headaches, depression and mild fever is known as _____.
a. chronic fatigue syndrome
b. febrile seizure
c. malaise
d. hypersomnia

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6. When no other diagnosis code quite fits the condition identified in the
physician’s documentation, you will _____.
a. determine a code that is close to accurate
b. not code the medical record
c. code from Chapter 16, which contains symptoms, signs and
ill-defined conditions
d. ask the physician to provide better documentation

7. A term used to describe an open wound INCLUDES _____.

a. laceration
b. superficial injury
c. burn
d. crushing injury

8. Which is not a true statement when coding burns? _____

a. Use the code for multiple burns any time more than one site
is documented.
b. You should code burns individually to the greatest extent possible.
c. When burns are documented at more than one site, you first sequence
the code for the site of the highest degree burn, sequencing the additional
codes for the other sites. Code in descending order of degree.
d. You will classify burns according to the highest degree recorded in the
diagnostic statement.

9. Which acronym does not accurately describe one of the four main
quadrants for category 789? _____
a. LLQ Left Lower Quadrant
b. RUQ Right Upper Quadrant
c. LUQ Lower Upper Quadrant
d. RLQ Right Lower Quadrant

10. Code 786.51 codes for _____.

a. pleuritic chest pain
b. anterior chest wall pain
c. precordial pain
d. all of the above

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Medical Coding and Billing Specialist

11. Which of the following terms identifies an open fracture? _____

a. greenstick
b. with foreign body
c. impacted
d. depressed

12. A sensation of unsteadiness with a feeling of movement might be

called _____.
a. dizziness
b. giddiness
c. light-headedness
d. all of the above

13. The _____ is the bone that extends from the shoulder to the elbow.
a. humerus
b. ulna
c. radius
d. forearm

14. The _____ consists of the manubrium, the body and the xiphoid process.
a. sternum
b. ribs
c. breast bone
d. both a and c

15. When coding clubbing of fingers as a symptom, you will assign code _____.
a. 736.29
b. 781.5
c. 754.89
d. none of the above

16. Displacement that leaves the bones in partial contact is called _____.
a. complete displacement
b. subluxation
c. dislocation
d. all of the above

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17. A distortion of the sense of taste, or bad taste in the mouth, is

termed _____.
a. parosmia
b. parageusia
c. anosmia
d. none of the above

18. Which is not a term used in the ICD-9-CM manual to describe a

superficial injury? _____
a. Abrasion
b. Insect bite
c. Contusion
d. Superficial foreign body

19. A(n) _____ is defined as any evidence of a disease or disorder (such as

pain) that is discovered.
a. symptom
b. unconfirmed diagnosis
c. uncertain conditions
d. none of the above

20. Which is not included in code category 788? _____

a. dysuria
b. urgency of urination
c. urinary incontinence
d. hematuria

For questions 21 through 35, choose the best diagnostic code(s) from the choices
provided. Each item is worth 2.86 points.

21. Methadone poisoning, accidental _____

a. 965.02
b. 965.02 E850.1
c. 965.02 E980.0
d. E850.1

22. Bead in ear _____

a. 382.9
b. 931
c. 388.70
d. 930.8

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23. Anterior dislocation of the elbow _____

a. 709.92
b. 832.00
c. 832.01
d. 832.11

24. Urinary incontinence _____

a. 788.32
b. 625.6
c. 788.31
d. 788.30

25. Adverse effect of allergic dermatitis due to insulin, therapeutic

use _____
a. 693.0 E932.3
b. 692.9 962.3 E932.3
c. 693.0 962.3 E932.3
d. 692.9 E932.3

26. LUQ abdominal pain _____

a. 789.00
b. 789.02
c. 789.09
d. 789.04

27. Comminuted fracture of distal humerus _____

a. 812.40
b. 812.44
c. 812.20
d. 812.50

28. Coma due to acute barbiturate intoxication, attempted suicide _____

a. 967.0 E950.1
b. 967.0 780.01 E950.1
c. 780.01 E950.1
d. 967.0 780.01 E950

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29. Laceration of external ear _____

a. 872.02
b. 872.69
c. 872.10
d. 872.00

30. Severe shock due to third-degree burns of the entire back.

Eighteen percent of the total body surface is burned. _____
a. 942.34 958.4
b. 942.34 948.1 958.4
c. 942.34 948.11 958.4
d. 957.1 958.4

31. Febrile convulsions _____

a. 780.31
b. 780.39
c. 780.6 780.39
d. 780.6

32. Hypokalemia resulting from reaction to Diuril given by mistake in

physician’s office _____
a. 974.3 E858.5
b. 974.3 276.8 E858.5
c. 974.3 276.8
d. 276.8 E858.5

33. Patient presents with 1st and 2nd degree burns to thumb and two
fingers. _____
a. 944.11 944.21 944.12 944.22
b. 944.21 944.22 948.00
c. 944.14 944.24 948.00
d. 944.24 948.00

34. Compound fracture of lower end of ulna _____

a. 813.53
b. 813.92
c. 813.43
d. 813.44

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35. Emergency Department Report

PREOPERATIVE DIAGNOSIS
Multiple complex lacerations of the orbital region.

POSTOPERATIVE DIAGNOSIS
Multiple complex lacerations of the orbital region.

PRIMARY PROCEDURE
CLOSURE OF MULTIPLE COMPLEX LACERATIONS.

ANESTHESIA
Local 1% with epinephrine.

ESTIMATED BLOOD LOSS

Minimal.

SPECIMEN
None.

COMPLICATIONS
None.

BRIEF HISTORY
The patient is a 19-year-old Caucasian male who presented status post a bicycle versus
MVA. The patient obtained multiple complex lacerations of the right orbital region.

PROCEDURE
Informed consent was properly obtained from the patient, and he was placed in a 45° angle.
Topical viscous lidocaine was applied for pain management, and then 1% epinephrine was
injected into the periorbital area for anesthetic effect. A #5-0 Vicryl suture was used to
close the deep layers, and then #6-0 Prolene was used in interrupted fashion for superficial
closure. The patient was instructed to take Keflex antibiotic for 10 days. He was also
instructed and given prescription for erythromycin ophthalmic ointment to be applied
to the periorbital areas t.i.d. The patient is to ice the area and to follow up in 1 week for
suture removal. The patient tolerated the procedure well, and he was discharged from the
emergency room in stable condition.

a. 918.9
b. 870.2
c. 921.9
d. 870.8

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Congratulations!
You have completed Lesson 28.

Drive
Terrific
n t !
Quality h me
l i s
o mp
A c c Learn
ing
Skillful

Do not wait to receive the results of your Quiz

before you move on.

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Medical Coding and Billing Specialist

28-58 0205502LB03A-28-13
 Lesson 29

Introduction to
V Codes,
Medical E Codes
Terminology:
and ICD-9-CM
Word Parts
Coding Practicum
 Step 1 Learning Objectives for Lesson 29
 When you have completed the instruction in this lesson, you will be trained to do the following:
 Define and identify factors and conditions classified in the
ICD-9-CM’s V codes and E codes.

 Identify the diagnoses, outline the coding pathway and assign the final code
for conditions that require the use of V codes and E codes.

 Review the steps for correct coding.

 Review Outpatient Coding Tips for accurate coding.

 Explain the sequencing guidelines.

 Assign ICD-9-CM diagnostic codes for outpatient medical records.

 Step 2 Lesson Preview

 Whew! You’re probably relieved to have reached the last ICD-9-CM coding lesson! But
just think about how much you’ve accomplished already. You’re well on your way to
becoming a medical coding and billing specialist. In this lesson you’re going to get a quick
review of all you’ve learned about diagnostic coding. Then you’ll be ready to tackle your
coding practicum.

Before we get to that practicum, though, there’s just a bit more we need to cover. We’re
going to discuss the V codes and E codes in your ICD-9-CM manual. As always, you’ll
learn when and how they’re used. And you’ll get some practice coding with them. You’ll
be a pro in no time!

We want to remind you one more time that your instructor is available to help you. You’ll
want to make sure you have all your questions answered before you take your practicum.
So don’t hesitate to call your instructor. Now, let’s get started with this lesson.

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Medical Coding and Billing Specialist

 Step 3 Supplementary Classification of Factors

Influencing Health Status and Contact with
Health Services (V01-V91)
 Turn in the Coding Guidelines in the front of your ICD-9-CM manual to C18,
Classification of Factors Influencing Health Status and Contact with Health Service
coding guidelines. As the guidelines indicate, there are four primary circumstances
for the use of V codes. They are used for those not currently sick, those with a
resolving disease, those with influencing factors to their health and for the birth
status of newborns. You can use some V codes as primary or secondary diagnosis
codes, while others can only be assigned as secondary diagnosis codes. Before we
discuss the specifics of this chapter, following is a list of main terms that indicate the
need for a V code:

Admission (encounter) for Aftercare Attention to

Boarder Care (of) Carrier
Checking (of) Contact Contraception, Contraceptive
Counseling Dialysis Donor
Examination Fitting (of) Follow-up
Health Healthy History
Maintenance Maladjustment Observation
Problem (with) Prophylactic Replacement by artificial or
mechanical device or prosthesis of
Screening (for) Status (post) Supervision (of)
Test (s) Transplant (ed) Unavailability of medical facilities (at)
Vaccination

Persons with Potential Health Hazards Related to

Communicable Diseases (V01-V06)
You will use the codes in this section to code for persons who receive medical
treatment as a result of their contact or exposure to various communicable diseases.
This section is also used for vaccinations and inoculations individuals receive to
protect against certain communicable diseases. Among the many communicable
diseases that are included in these code groups are anthrax, cholera, the common
cold, encephalitis, hepatitis, influenza, measles, plague, poliomyelitis, rabies,
rubella, smallpox, tetanus, tuberculosis, typhoid, venereal diseases and other viral
diseases. Vaccinations and inoculations also include those available for the diseases
mentioned here and others.

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 V Codes, E Codes and ICD-9-CM Coding Practicum

Contact or Exposure
When a person has been exposed to a disease but does not show signs or symptoms
of the disease, you will use code category V01. Assigning this code as a principal
diagnosis indicates the need for testing. As a secondary diagnosis, code V01
identifies the potential risk for the person to contract the disease.

Take a look at the following SOAP note, and then practice coding the diagnosis.
When you’re done, compare your results to the summary that follows.

SUBJECTIVE
A 9-year-old male who presents with a fever is seen by the family doctor.
The boy’s sister was diagnosed with chickenpox last week.
OBJECTIVE
Physical exam reveals a low-grade fever. No rash.
ASSESSMENT
Fever. Rule out chickenpox.
PLAN
Patient will be sent for a blood test to verify whether the varicella-zoster
virus is present.

Chickenpox is not confirmed at this time, so you cannot code it. You will code the
fever and the fact that the patient has been exposed to the varicella virus. To do so,
first locate Fever in the Index to Diseases, where you will find the tentative code of
780.60. Be sure to verify that code in the Tabular List. Then turn to Exposure, in
the Index to Diseases, and locate to, varicella, with a tentative code of V01.71. The
Tabular List indicates that code V01.71 is correct. You will assign 780.60 Fever
as the principal diagnosis because the fever is the reason for the visit, and V01.71
Contact with or exposure to communicable diseases, Other viral diseases,
Varicella as the coexisting diagnosis and the reason for the blood test.

Inoculations and Vaccinations

You will assign codes from V03 through V06 when the patient is being seen for
inoculations and vaccinations. When the vaccinations are given as part of the well
baby visit, you can assign codes V03 through V06 as secondary codes to the well
baby code.

Let’s say a 68-year-old female is seen at the clinic for a flu (influenza) vaccination.
To assign the ICD-9-CM code for this encounter, locate Vaccination, prophylactic,
influenza with a tentative code of V04.81. Find this code in the Tabular List. The
information there will confirm that V04.81 Need for prophylactic vaccination
and inoculation against certain viral diseases, Other viral diseases,
Influenza is the accurate code for this encounter.

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Medical Coding and Billing Specialist

Persons with Need for Isolation, Other Potential Health

Hazards and Prophylactic Measures (V07-V09)
Prophylactic measures are tactics used to prevent a disease. In a previous lesson,
in the “Certain Conditions Originating in the Perinatal Period” section, we discussed
Rh isoimmunization. Remember that this is the situation in which the mother is Rh
negative and the fetus is Rh positive, and the mother develops antibodies against
the “foreign” blood of the fetus. When antibodies cross the placenta, they destroy
the infant’s red blood cells. Testing can be done to determine whether the Rh factor
might be a problem in the pregnancy. Rh-immune globulin can be given to the
mother at 28 weeks into the pregnancy to help prevent the destruction of the red
blood cells in the fetus. This is an example of prophylactic immunotherapy, and will
be coded V07.2.

Persons with Potential Health Hazards Related

to Personal and Family History (V10-V19)
History codes are important because they might alter the type of treatment ordered.
Applying a personal history code indicates that the condition no longer exists and
the patient is no longer receiving treatment for that condition. The potential for
recurrence or the development of other conditions still exists, and therefore the
patient requires careful monitoring. Family history of certain conditions causes
the patient to be at a higher risk for those conditions, as well. History codes can be
assigned to any medical record regardless of the reason for the visit.

Persons Encountering Health Services in Circumstances

Related to Reproduction and Development (V20-V29)
The following guidelines govern your selection of the principal diagnosis when the
encounter is for obstetric care other than delivery:
 The principal diagnosis should correspond to the complication of the
pregnancy that necessitated the admission or encounter. If more than one
complication is present, all of which are treated or monitored, you can
first sequence any of the complication codes.

 For routine prenatal visits when no complications are present, you will
assign code V22.0 or V22.1 as the reason for the encounter.

 When the admission or encounter is for the care of a condition totally

unrelated to the pregnancy, you will assign code V22.2 as an additional code.

 You can assign a code from category V23 either as the principal
diagnosis or as an additional diagnosis when a pregnant patient is in
a high-risk category.

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 V Codes, E Codes and ICD-9-CM Coding Practicum

 When a patient delivers outside of the hospital and is then admitted for
routine postpartum care with no complications present, you will assign
V24.0 as the principal diagnosis.

 If a patient encounter is for the purpose of prenatal screening for fetal

abnormality, you will assign a code from category V28, with the fourth
digit indicating the area of concern.

The codes for encounters for routine exams

and general check-ups are found located
within this section. Routine infant or child
health check, coded to V20.2 Routine
infant or child health check, includes
developmental testing, immunizations and
routine vision and hearing testing. When
coding “well child care,” you will use the
coding pathway of Examination, health (of),
child, routine to locate V20.2. When the
vaccinations are given as part of the well-
baby visit, you can assign codes V03 through Routine infant or child health checks include
V06 as secondary codes, but these codes are developmental testing, immunizations and
not required. routine vision and hearing testing.

For example, an eight-month-old female is seen by her pediatrician for a well child
exam and receives a DTaP vaccination. DTaP stands for diphtheria, tetanus toxoids
and acellular pertussis. In this scenario, you will code V20.2, as determined above,
for the well child examination. This is the only necessary code, but you can code
for the vaccination as a secondary diagnosis. To do so, locate the coding pathway
of Vaccination, prophylactic, diphtheria, with tentanus, pertussis combined in the
Index to Diseases. DTaP is indicated in parentheses and the tentative code V06.1
is provided.

Turn to the Tabular List to verify this code. You would assign V20.2 Health
supervision of infant or child, Routine infant or child health check
and V06.1 Need for prophylactic vaccination and inoculation against
combinations of diseases, Diphtheria-tetanus-pertussis, combined [DTP]
[DTaP] for this scenario.

Normal pregnancy can be classified as V22.0 Supervision of normal first

pregnancy, V22.1 Supervision of other normal pregnancy, or V22.2 Pregnant
state, incidental. You will use these codes for normal, routine, prenatal visits.
These codes are usually the principal diagnosis.

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Medical Coding and Billing Specialist

Persons with a Condition Influencing Their Health Status

(V40-V49)
A status code is important because the individual’s health “status” might affect the
course of treatment and its outcome. For instance, let’s say a person complains of
chest pain and her status is “postcoronary artery bypass graft” or post CABG. If
you code only to the chest pain, that code does not provide the entire story. The fact
that the person had the CABG indicates a previous problem with the heart. The
current chest pain might be related to the CABG or the previous problems, but the
conditions also might not be related. The physician may order additional tests or
require a higher level of service because of the uncertainty. To code for this example,
you will locate Pain, chest with a tentative code of 786.50 and Status (post), coronary
artery bypass or shunt with a tentative code of V45.81. To confirm these codes, be
sure to determine the highest level of specificity in the Tabular List before you
assign them.

Persons Encountering Health Services for Specific

Procedures and Aftercare (V50-V59)
When the initial treatment of a disease or injury has been completed, but
continued care is required during the healing or recovery time, aftercare V codes
are assigned. These codes are generally the principal codes because the conditions
they specify are the reason for the encounter. The code for a person seen to have
a hearing aid fitted will be coded from this category. The coding pathway Fitting,
hearing aid suggests the tentative code of V53.2. Turning to the Tabular List and
reviewing the information there confirms that V53.2 Fitting and adjustment of
other device, Hearing aid is the correct code.

You will use codes in category V59 for living individuals who are donating blood
or other body tissue to others. This code group is not for self-donations. In other
words, you do not use code V59 to identify cadaveric, or dead body, donations.

Persons Encountering Health Services in Other

Circumstances (V60-V69)
You will find housing, household and economic circumstances are found in code
category V60. These circumstances includes inadequate housing and lack of housing,
to persons living alone. Counseling codes, which are a large portion of this section,
have two classifications. First, you will use counseling codes to describe assistance
in the aftermath of an illness or injury. Second, you will use them when support is
required for individuals to cope with family or social problems. You can use these in
conjunction with a diagnosis code but doing so is not necessary.

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Persons Without Reported Diagnosis Encountered During

Examination and Investigation of Individuals
and Populations (V70-V82)
Screening refers to testing for any number of disease indicators in seemingly well
individuals, so that early detection and treatment can be provided for those who
test positive. A routine mammogram, code V76.12, is an example of this type of
screening. Code V76.12 is the principle diagnosis, and it indicates the reason for the
screening is a routine mammogram. The diagnosis code V76.12 must be specific to
that type of screening with the procedure documented. If a condition is discovered
during the screening, you will then code that condition as an additional diagnosis.
Testing to “rule out” or “confirm” a suspected diagnosis does not fall into the
category of screening. When testing is documented for these purposes, you will code
to the signs or symptoms of the unconfirmed diagnosis.

To help clarify these guidelines related to screening codes, review the following
SOAP note and the explanation about how you would determine the correct codes.

SUBJECTIVE
This pleasant 54-year-old female, with a history of left mastectomy due to
estrogen-sensitive breast cancer, was sent by her oncologist to have a
fractional curettage. The patient states she has been on 20 mg tamoxifen
once daily for the past 2 years. Her oncologist informed her that one of the
side effects of tamoxifen is endometrial carcinoma and encouraged her to
have this test done by her gynecologist.
OBJECTIVE
Blood pressure: 112/80. Pulse: 76, regular. Respiratory rate: 14. Temperature:
96.8 ºF. Lungs: Clear to P&A. Tissue sample was taken from the endometrial
lining. Patient tolerated procedure well.
ASSESSMENT
Histological confirmation was negative for carcinoma.
PLAN
Continue tamoxifen as ordered. Return if any abnormal cramping or
bleeding occurs.

When endometrial carcinoma is a possibility, either from a personal or family

history, the physician can order fractional curettage. Because tamoxifen is
taken to reduce the chances of the patient’s breast cancer from reoccurring, and
a side effect of this drug is endometrial carcinoma, a fractional curettage can
be justified. You will use a V code to establish that the patient has a personal
history of a malignant neoplasm.

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Medical Coding and Billing Specialist

For these SOAP notes, you will code the screening for the malignant neoplasm and
the patient’s personal history of breast cancer. The coding pathway for the screening
is Screening, malignant neoplasm, specified sites with a tentative code of V76.49.
The personal history coding pathway is History of, malignant neoplasm, breast, with
a tentative code of V10.3. When you have verified the codes in the Tabular List, you
will assign V76.49 Special screening for malignant neoplasms, Other sites
and V10.3 Personal history of malignant neoplasm, Breast for this dictation.

The code categories not specifically highlighted in this section are fairly
straightforward to code. Just use the Index to Diseases carefully and read the notes
in the Tabular List before assigning a code.

It’s time for a Practice Exercise to review and apply what you’ve learned in this
portion of the lesson. It won’t be long now until you have completed this introduction
to ICD-9-CM coding and be ready to demonstrate your coding expertise in this area!

 Step 4 Practice Exercise 29-1

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Metastatic carcinoma to the brain, with a personal history of

breast cancer
ICD-9-CM code: ____________________________
ICD-9-CM code: ____________________________

2. Chest pain, status postsurgical

ICD-9-CM code: ____________________________
ICD-9-CM code: ____________________________

3. Normal delivery of a single liveborn infant

ICD-9-CM code: ____________________________
ICD-9-CM code: ____________________________

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 V Codes, E Codes and ICD-9-CM Coding Practicum

4. ICD-9-CM Coding Challenge

GYNECOLOGICAL CONSULTATION REPORT
REASON FOR REFERRAL
Patient referred for pelvic examination as part of routine physical before beginning diet
and exercise program. The patient is 10 lb overweight, otherwise feeling fine.

PAST HISTORY
The patient does not smoke or drink. Usual childhood diseases. No serious illnesses. NO
KNOWN DRUG ALLERGIES.
FAMILY HISTORY
Parents and four siblings alive and well. No family history of breast cancer or uterine cancer.

REVIEW OF SYSTEMS
GASTROINTESTINAL: Stools brown. No diarrhea or constipation. No nocturia or hematuria.
GYNECOLOGIC: Last regular menses two days ago. Sexually active. No birth control
methods used. Breast tenderness, only premenstrual.

PHYSICAL EXAMINATION
GENERAL: This is a well-nourished, well-developed 26-year-old female in no acute
distress. Alert and oriented. Pulse: 80/min. Blood Pressure: 100/80. Respiratory Rate:
20/min. Temperature: 98.6 ºF.
NECK: No thyromegaly.
CHEST: Clear to auscultation and percussion. Heart: Regular rate and rhythm.
Normal heart tones. No murmurs. Breasts: Symmetrical. No masses or discharge.
ABDOMEN: Soft and slightly full in the suprapubic region. No masses or
organomegaly palpated.
PELVIC: Normal perineum. Bimanual: Uterus nongravid, anteflexed, and anteverted.
No enlargement, masses or fixation. No adnexal masses or fixation. Cervical smears
obtained. No cervical erosions. No cul-de-sac fluid.
RECTAL: No blood on the examining glove. Stool guaiac negative.
DATABASE: CBC normal. Electrolytes: Na 138, K 4.3, Cl 97, pH 7.4. Pap smear results
pending. Stool guaiac negative.
ASSESSMENT
Normal gynecologic examination.
PLAN
Call office in one week for results of Pap smear. Agree with diet plan.

ICD-9-CM code: _________________________________________

 Step 5 Review Practice Exercise 29-1

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

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Medical Coding and Billing Specialist

 Step 6 Supplementary Classification of External

Causes of Injury and Poisonings (E000-E999)
 External causes, or E codes, identify environmental events, circumstances and conditions
that relate to the cause of injury, poisoning and other adverse effects. We’ve explained the
use of E codes in relation to poisoning. They are used to identify the cause as accidental, a
suicide attempt, an assault or of undetermined intent. We’ve discussed adverse effects and
how to code for the manifestation and identification of the therapeutic use of a drug. Now
it’s time to discuss the use of E codes in relation to injuries.

E codes are supplemental to the diagnostic coding and are never to be used as
principal diagnosis codes. You are not required to report these codes to the Centers
for Medicare and Medicaid Services (CMS). E codes are intended to provide data for
research and analysis for injury prevention. Some physicians do not report E codes
unless the case is one of poisoning or of adverse effects or unless directed to by the
principal diagnosis. You will want to verify with your provider whether you are to
apply E codes in other instances. The rules that follow apply to those circumstances
in which the provider requests coding of the external causes in all circumstances.
 You might code the external cause with any diagnosis.

 To indicate how and where the accident occurred, if that information is

known, you will code the external cause with any diagnosis in the range of
codes 800 through 999.

 You are to assign as many E codes as necessary to fully describe each

cause of injury.

To locate the appropriate E code, you will use the Index to External Causes of
Injury and Poisonings (E code), which you will find in Section 3 of Volume 2 of the
ICD-9-CM manual. This section comes just before the Tabular List. Using the index
to E codes is similar to using the Index of Diseases; you will locate the main term,
followed by the subterm. Once you have a tentative code, you will turn to the E
codes in the Tabular List to verify its accuracy. Let’s code an injury and include the
external cause to give you some practice applying E codes.

SUBJECTIVE
A 10-year-old boy is seen in the physician’s office with a right-ankle injury. He
was injured 24 hours ago when he fell down steps at home.
OBJECTIVE
Ankle appears erythematous and swollen. It is tender to the touch. Patient
walks with a hint of a limp. X-ray rules out fracture.
ASSESSMENT
Patient has an ankle sprain.
PLAN
Recommend ibuprofen as needed for pain.

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 V Codes, E Codes and ICD-9-CM Coding Practicum

For this scenario, you will code the diagnosis, as well as how and where the injury
happened. First, the diagnosis is the sprained ankle. Using the coding pathway of
Sprain, strain, ankle, you find the tentative code of 845.00 in the Index to Diseases.
Confirm that code in the Tabular List. Now, turn to the Index to External Causes of
Injury and Poisonings (E Code) located in Section 3 of Volume 2 to code the how and
where of the injury. The sequencing of E codes does not matter as long as the injury
is the primary ICD-9-CM. To code how the injury occurred, locate Fall, falling, down,
stairs, steps and you are directed to see Fall, from, stairs. This pathway suggests code
E880.9. Now, to code where the injury happened, you locate Accident (to), occurring
(at) (in), house (private) (residential). The tentative code provided for this pathway is
E849.0. You’ll then turn to the Tabular List to confirm these codes. You will assign
the following sequence of codes for this scenario: 845.00 Sprains and strains
of ankle and foot, Unspecified site, E880.9 Fall on or from stairs or steps,
Other stairs or steps and E849.0 Place of occurrence, Home.

Remember, you are to use E codes for injuries if the provider has requested that
you do so. For your lessons in this course, you are not required to include E codes
for injuries. If you would like to try your hand at using E codes to code external
causes for codes 800 through 900 codes, that would be great practice for you. Just
remember that in these circumstances you use E codes in addition to the required
codes. Finally, you will include E codes for poisonings, adverse effects and when the
Tabular List notes indicate that you are to identify the external cause.

Now it’s time to review what you’ve just learned about E codes and complete the
following Practice Exercise. Then you’ll be ready to proceed to the review and Practicum.

 Step 7 Practice Exercise 29-2

 Determine the correct ICD-9-CM code(s) for the following conditions.

1. Patient fell from a skateboard while at the park, resulting in a

sprained wrist.
ICD-9-CM code: ____________________________
ICD-9-CM code: ____________________________
ICD-9-CM code: ____________________________

2. Passenger on railway suffers third-degree burns to front and back

of both legs, involving 33% TBSA, due to railway explosion.
ICD-9-CM code: ____________________________
ICD-9-CM code: ____________________________
ICD-9-CM code: ____________________________

0205502LB03A-29-13 29-11
Medical Coding and Billing Specialist

3. Two-car collision resulting in contusions of abdomen of passenger of

second car
ICD-9-CM code: ____________________________
ICD-9-CM code: ____________________________

4. Fractured distal radius due to falling at home

ICD-9-CM code: ____________________________
ICD-9-CM code: ____________________________
ICD-9-CM code: ____________________________

 Step 8 Review Practice Exercise 29-2

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 9 Practicum Preview

 Congratulations, you’ve made it through the entire ICD-9-CM! You now have the
knowledge to be able to locate diagnostic codes. The past lessons contained an
abundance of information pertaining to diseases. Not only did you learn about the
diseases, but you are accustomed to the coding process as well! This material contains
a variety of scenarios so that you will become familiar with coding situations. These
scenarios give you real-life experiences coding the ICD-9-CM book from a physician’s
dictation. When you code for a physician, only the ICD-9-CM codes are recorded. You
will not record “NEC,” “NOS” or check marks. You will not write pathways or code
descriptions. Only the ICD-9-CM code is necessary for diagnostic coding. This is the
case for graded quizzes as well, unless indicated otherwise. Now, let’s get started
on this comprehensive material relative to the ICD-9-CM codes. Keep focused on
the steps in coding. Remember the outpatient coding rules. Be sure you follow the
sequencing guidelines provided. With these in mind, you’ll be able to code accurately
with confidence!

 Step 10 Guidelines for Assigning Codes

 When you assign diagnostic codes to outpatient records, there are a few guidelines to
consider as you code. The guidelines in this section will give you a checklist to review
as you code. Familiarize yourself with these steps and keep them handy. Don’t worry
about memorizing them, you will soon know the guidelines well enough that you will
only need to refer to them occasionally.

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Steps for Assigning Diagnostic Codes

1. Identify the main terms in the diagnostic statement.
2. Locate each main term in the Index to Diseases and read any notes that appear
with the main term.
3. Refer to any subterms indented under the main term in the Index to Diseases.
4. Look at abbreviations, cross-references, symbols and brackets.
5. Choose the tentative code you find in the Index to Diseases, Volume 2, then locate
and determine the highest level of specificity in the Tabular List, Volume 1.
6. Read and use any instructional terms in the Tabular List as a guide. Look for
INCLUDES and EXCLUDES , notes and other instructional comments at the
beginning of each chapter. Also, look at the three-digit code at the beginning of
each category or group of codes that you are using within the chapter and check
for additional instructions for the group.
7. Assign codes to their highest level of specificity, using the following guidelines:
 Assign three-digit codes only when there are no four-digit codes within
that category.

 Assign a four-digit code only when there is no fifth-digit subdivision for

that subcategory.

 Assign a fifth-digit to the code for any subcategory for which a fifth-digit
subclassification is provided.

 Remember to continue coding the dictation until all elements are fully
identified before assigning the code.

Outpatient Coding Tips

 If it is not documented, it did not happen.
 Do not assume anything.
 Terms such as possible, suspect, probable, rule out or consistent with
are not assigned codes.
 Code symptoms only when a definitive diagnosis is not documented.
 Check with the physician if the information is unclear.

0205502LB03A-29-13 29-13
Medical Coding and Billing Specialist

Sequencing ICD-9-CM Codes

The principal diagnosis reflects the current and most significant reason the patient
is seeking treatment when you code a physician’s diagnosis of a patient. The
ability to sequence the ICD-9-CM codes in the correct order is a learning process. A
principal diagnosis is the condition that is responsible for the current episode of care.

Multiple Coding—Multiple coding means that two or more codes are necessary to
fully describe the patient’s condition. The Tabular List provides instructions for
multiple coding. “Use additional code” and “code first underlying disease” indicate
another code is necessary and the sequence in which the codes are to be written.
Turn in the Tabular List to code 652. The notes direct you to “code first any
associated obstruction.” Which means code 660.0 is the principal diagnosis and the
appropriate 652 code will be a coexisting condition.

Mandatory Codes—The slanted brackets in the ICD-9-CM indicate that you must
use both codes and sequence them in the order listed. Let’s use diabetic cataracts as
an example. Locate Diabetes, cataract in the Index to Diseases and you are provided
250.5  [366.41]. You would list the codes 250.50 and 366.41 for this condition
and sequence them in this order as well.

Combination Codes—When a single code describes conditions that frequently

occur together, it is a combination code. An open wound of the finger with tendon
involvement is coded with a single code of 883.2. Coding to the open wound of the
finger and then coding tendon involvement as a separate code is not necessary.

Coexisting diagnosis codes should be related to the current episode of care. If the
coexisting conditions have no bearing on the care of the principal diagnosis, they should
not be coded. For example, a blind woman is diagnosed with a URI. Being blind has no
impact on how the URI will be treated and is not coded as a coexisting condition.

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 Step 11 Practice Exercises 29-3, 29-4

 Read the following SOAP reports to assign the appropriate ICD-9-CM code(s)
for each dictation. Record the diagnostic code in the space(s) provided.

Practice Exercise 29-3

SUBJECTIVE
Patient underwent exploratory laparotomy 3 days previously for bowel
obstruction. There were 2 days of fever postoperatively. Today is the 3rd
postoperative day.
OBJECTIVE
There is redness and swelling of the wound with pus emanating from around the
suture material.
ASSESSMENT
Postoperative wound infection.
PLAN
Obtain culture of wound for E. coli. Open wound, debride with acetic acid and
pack with W-70 dressings. Prescription for cephradine 500 mg 1 p.o. q.6 h.

___________________________________________

Practice Exercise 29-4

SUBJECTIVE
This is a 56-year-old female with a history of type 2 diabetes for the past 4
years and has been using insulin long-term. She has noticed decreased vision
in both eyes for the past 1 year. She was seen in the eye clinic 2 weeks ago
where fluorescein angiography revealed vitreous hemorrhages. The patient was
scheduled for vitrectomy to extract the contents of the vitreous chamber.
OBJECTIVE
Ophthalmoscopy reveals proliferative retinopathy resulting in blood staining the
vitreous humor. Tonometer reveals tension in both eyes is 14.
ASSESSMENT
Diabetic retinopathy.
PLAN
Vitrectomy. Maintain control of diabetes and blood pressure.

___________________________________________

___________________________________________

___________________________________________

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Medical Coding and Billing Specialist

 Step 12 Review Practice Exercises 29-3, 29-4

 Check your answers with the Answer Key at the end of this book. Correct any
mistakes you may have made.

 Step 13 Practice Exercises 29-5, 29-6

 Read the following radiology reports to assign the appropriate ICD-9-CM code(s) for
each dictation. Record the diagnostic code(s) in the space(s) provided.

Practice Exercise 29-5

TWO-VIEW CHEST X-RAY
No old films are available for comparison. Consolidation is present in the lower
lobes bilaterally. A right-sided chest tube is present. There is a small amount of
subcutaneous emphysema against the right chest wall. The most proximal portion
of the chest tube lies within the margins of the rib cage.
IMPRESSION
1) Bilateral lower lobe pneumonia.
2) Right-sided chest tube. No significant pneumothorax is evident.

___________________________________________

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 V Codes, E Codes and ICD-9-CM Coding Practicum

Practice Exercise 29-6

LUMBAR SPINE MRI WITHOUT CONTRAST
HISTORY
Low back pain.
TECHNIQUE
Sagittal and axial proton density and T2-weighted sequences were obtained
through the lumbar spine.
COMPARISON
April 30, 20XX plain film lumbar spine.
FINDINGS
Examination demonstrates normal alignment of the lumbar spine. The conus
medullaris is located posterior to the L1 vertebral body. There is no evidence of
abnormal signal within the lumbar vertebral bodies.
Disc spaces:
L1-L2: Unremarkable.
L2-L3: Unremarkable.
L3-L4: At this level, there is mild disc desiccation. There is a small left lateral disc
protrusion. There is mild left neural foraminal stenosis. There is no significant
right neural foraminal stenosis. There is no significant spinal stenosis.
L4-L5: At this level, there is minimal diffuse disc protrusion. This does not
cause significant neural foraminal stenosis or spinal stenosis.
L5-S1: At this level, there is a small central disc protrusion. This does not cause
significant neural foraminal stenosis or spinal stenosis.
IMPRESSION
Very mild lumbar spondylopathy. At the level of L3-L4, there is a left lateral
disc protrusion.

___________________________________________

___________________________________________

 Step 14 Review Practice Exercises 29-5, 29-6

 Check your answers with the Answer Key at the end of this book. Correct any
mistakes you may have made.

0205502LB03A-29-13 29-17
Medical Coding and Billing Specialist

 Step 15 Practice Exercises 29-7, 29-8, 29-9

 Read the following History and Physical Examination reports to assign the
appropriate ICD-9-CM code(s) for each dictation. Record the diagnostic code in the
space(s) provided.

Practice Exercise 29-7

ORTHOPEDIC CONSULTATION REPORT
REASON FOR REFERRAL
Continuous pain, right ankle and foot.
HISTORY OF PRESENT ILLNESS
This patient has severe arthritic destructive disease in the right subtalar joint.
She cannot walk because of continuous pain in the ankle and foot. Any inversion
or eversion causes immediate severe discomfort. The patient has had long-
standing, severe osteoporosis and rheumatoid arthritis. In addition, she has
been on long-term steroid therapy. The patient has spontaneously fractured ribs
with delayed healing.
PAST HISTORY
Medications: Long-term corticosteroid therapy for rheumatoid arthritis. Currently,
prednisone 40 mg daily p.o.
Illnesses: Rheumatoid arthritis, osteoporosis.
ALLERGIES: NO ALLERGIES TO FOOD OR MEDICATION.
Social history: The patient was employed as a plumber until the age of 50 when
progressive arthritis limited her ability to continue working.
Family history: There is no family history of cancer, diabetes. A paternal uncle and
a sister have RA.
REVIEW OF SYSTEMS
CARDIORESPIRATORY: Pleuritic pain and dyspnea and focal pain over the left
4th, 5th and 6th ribs began one week ago spontaneously. No history of trauma.
PHYSICAL EXAMINATION
GENERAL: This is a 65-year-old, 180-pound white female in moderate distress.
Pulse: 100 and regular. Blood pressure: 140/110. Respiratory rate: 20, guarded.
Temperature: 99.6 °F.
CHEST: There is pinpoint tenderness over the left 4th, 5th and 6th ribs in
the left midaxillary line. Heart: PMI left midclavicular line. Regular rate and
rhythm without murmurs. Lungs: Clear.
NEUROLOGIC: There is a decrease in sensation in the right ankle and foot.
Cranial nerves 2-12 are intact.
DATABASE
A bone survey shows diffuse, widespread changes of rheumatoid arthritis with
destruction of taloscaphoid axis and pronation of the right foot.

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 V Codes, E Codes and ICD-9-CM Coding Practicum

ASSESSMENT
1. Rheumatoid arthritis with severe destructive diseases of the subtalar joint,
right ankle and foot.
2. Spontaneous pathologic fractures, left ribs 4-6.
3. Osteoporosis.
RECOMMENDATIONS
The severe pain and limitation of motion of right foot argues in favor of triple
arthrodesis with bone graft from the right iliac crest to the right subtalar joint
and transfer of the peroneal tendons of the right ankle. It is well known that
the patient has severe osteoporosis and spontaneously fractured ribs. However,
because of the severity of the destruction of the right ankle, arthrodesis is
recommended at this time.

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

0205502LB03A-29-13 29-19
Medical Coding and Billing Specialist

Practice Exercise 29-8

CHIEF COMPLAINT
Follow-up on diabetes mellitus, status post cerebrovascular accident.

HISTORY OF PRESENT ILLNESS

This is a 70-year-old male who has no particular complaints other than he has discomfort on his
right side. We have done EMG studies. He has noticed it since his stroke about 5 years ago. He
has been to see a neurologist. We have tried different medications, and it just does not seem to
help. He checks his blood sugars at home 2-3 x a day. He kind of adjusts his own insulin himself.
Re-evaluation of symptoms is essentially negative.

PAST HISTORY
Habits: He has a past history of heavy tobacco and alcohol usage.
Medications: Refer to chart.
ALLERGIES: REFER TO CHART.

PHYSICAL EXAMINATION
GENERAL: A 70-year-old male who does not appear to be in acute distress but does look older
than his stated age. He has some missing dentition.
VITAL SIGNS: Weight: 118 pounds. Pulse: 80 and regular. Blood pressure: 108/72. Temperature
96.5.
SKIN: Dry and flaky.
CHEST: Cardiovascular: Heart tones are okay, adequate carotid pulsations. He has 2+ pedal
pulse on the left and 1+ on the right. Lungs: Diminished but clear.
ABDOMEN: Scaphoid.
RECTAL: His prostate check was normal.
NEUROLOGIC: Sensation with monofilament testing is better on the left than it is on the right.

IMPRESSION
1. Diabetes mellitus, type 2 with long-term insulin.
2. Neuropathy.
3. Late effects of cerebrovascular disease.

PLAN
Refill his medications x 3 months. We will check a BMP. I have talked to him several times about
a colonoscopy, which he has refused, and so we have been doing stools for occult blood. We will
check a PSA. Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in
3 months and p.r.n.
___________________________________________

___________________________________________

___________________________________________

___________________________________________

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 V Codes, E Codes and ICD-9-CM Coding Practicum

Practice Exercise 29-9

EMERGENCY DEPARTMENT REPORT
HISTORY
CHIEF COMPLAINT
Pain and deformity of distal right forearm.
HISTORY OF PRESENT ILLNESS
The patient was in good health until today when he fell over a Doberman while
walking down a sidewalk. He fell on his outstretched arm, resulting in severe
pain and deformity of the distal right forearm.
PHYSICAL EXAMINATION
GENERAL: The patient appears in some distress with acute pain in the distal
right forearm.
VITAL SIGNS: Pulse: 78/min. Blood pressure: 150/88. Temperature: Normal.
EXTREMITIES: There is palpable deformity over the distal radius with 1/5
opposition and strength in the right hand and 4+ swelling in the right wrist.
DATABASE
CBC and electrolytes are normal. X-ray confirms Colles fracture.
IMPRESSION
Colles fracture.
PLAN
Refer to orthopedic surgery clinic for reduction and immobilization. Right
forearm sling and wrist immobilizer.

___________________________________________

 Step 16 Review Practice Exercises 29-7, 29-8, 29-9

 Check your answers with the Answer Key at the end of this book. Correct any
mistakes you may have made.

0205502LB03A-29-13 29-21
Medical Coding and Billing Specialist

 Step 17 Practice Exercises 29-10, 29-11, 29-12

 Read the following Operative reports to assign the appropriate ICD-9-CM code(s) for
each dictation. Record the diagnostic code(s) in the space(s) provided.

Practice Exercise 29-10

PREOPERATIVE DIAGNOSIS
Persistent leukocytosis of unknown etiology.
POSTOPERATIVE DIAGNOSIS
Same, pending pathology.
PRIMARY PROCEDURE
ASPIRATION OF BONE MARROW FROM RIGHT POSTERIOR ILIAC CREST.
PROCEDURE
The patient was placed in a prone position. The posterior iliac crest was palpated,
and the biopsy site was marked. A 26-gauge needle was used to inject 1% lidocaine
solution subcutaneously. A 22-gauge needle was then used to infiltrate the deeper
tissues with lidocaine. A #11 scalpel blade was used to make a 2 mm skin incision of
the biopsy site. The bone marrow biopsy needle was firmly seated on the periosteum,
advanced through the outer table of bone and into the marrow cavity with rotating
motion and gentle pressure. It was advanced 2 mm. The stylet was removed, and a
10 mL syringe was attached to the needle hub. A brisk withdrawal of the plunger
resulted in 2 mL of marrow aspiration. The site was observed for any excess
bleeding, cleaned thoroughly with alcohol, and a gauze patch secured the site.
The patient was in satisfactory condition with no operative complications noted.

_________________________________________

Practice Exercise 29-11

PREOPERATIVE DIAGNOSIS
Hemorrhoids.
POSTOPERATIVE DIAGNOSIS
Thrombosed internal hemorrhoids.
PRIMARY PROCEDURE
HEMORRHOIDECTOMY.
PROCEDURE
The patient was taken to the operating room and placed in the prone position. A
large internal hemorrhoid, which was significantly thrombosed, was palpated.
After allowing adequate time for the anesthesia to take effect, the hemorrhoid was
grasped with a clamp while another clamp was placed at the base of the hemorrhoid.
The hemorrhoid was excised above the clamp, and a running stitch going in the
opposite direction was looped over the clamp. The clamp was then removed, and
the stitch was tightened. The area was dressed and packed with gauze. The patient
tolerated the procedure well and was discharged to the postanesthesia care unit.

_________________________________________

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 V Codes, E Codes and ICD-9-CM Coding Practicum

Practice Exercise 29-12

PREOPERATIVE DIAGNOSIS
Medial and lateral meniscus tears, left knee.
POSTOPERATIVE DIAGNOSIS
Same.
PRIMARY PROCEDURE
ARTHROSCOPY WITH MEDIAL AND LATERAL MENISCECTOMIES,
LEFT KNEE.
PROCEDURE
The patient was placed on the operating table in the supine position under general
anesthesia, administered by the anesthesiologist. Arthroscopy was carried out
beginning in the inferolateral portal.
After initial exploration, the medial compartment was explored. The arthroscopy
exposed the meniscus which revealed a tear. The torn portion was removed
with forceps.
Attention was then turned to the lateral compartment which also revealed a tear in
the lateral meniscus. The torn portion was removed with forceps.
After completion of the meniscectomies, there were no other significant findings.
Dressing was applied. The patient tolerated the procedure well and left the
operating room in good condition.

___________________________________________

___________________________________________

 Step 18 Review Practice Exercises 29-10, 29-11,29-12

 Check your answers with the Answer Key at the end of this book. Correct any
mistakes you may have made.

 Step 19 Lesson Summary

 Your diagnostic coding practice of health records is complete. If you are still feeling a
little unsure of yourself, that’s OK. As you review the Practice Exercise answers and
compare them to your pathways, contact your instructor with any questions. The
best way to determine why you didn’t get to the correct code is to understand the
pathway used. As you practice, you’ll become faster and more proficient at coding.
Now, let’s move on to the comprehensive ICD-9-CM Quiz!

0205502LB03A-29-13 29-23
Medical Coding and Billing Specialist

 Step 20 Mail-in Quiz 29

 Follows the steps to complete the Quiz.

a. Be sure you’ve mastered the instructions and the Practice Exercises that
this Quiz covers.
b. Mark your answers on your Quiz. Remember to check your answers with
the lesson content.
c. When you’ve finished, transfer your answers to the Quiz Cover Sheet. Use
only blue or black ink.
d. Important! Please fill in all information requested on your Quiz Cover
Sheet or when submitting your Quiz online.
e. Submit your answers to the school via mail, fax or, to receive your grade
immediately, submit your answers online at www.uscareerinstitute.edu.

Mail-in Quiz 29
Part 1 True or False
Circle to indicate if the statement is true or false. Each item is worth 0.5 points.

1. A normal delivery is the spontaneous, full-term birth of one live

baby, delivered vaginally, head first, with no fetal manipulation or
instrumental assistance except for an episiotomy.
True
False

2. Category 717 includes codes for the internal derangement of the knee,
which is the disturbance of the regular order or arrangement.
True
False

3. Peptic ulcers are not found in the esophagus, stomach or duodenum.

True
False

4. Spina bifida is always associated with an excess accumulation of spinal

fluid within the ventricles, known as hydrocephalus.
True
False

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5. Eczema is an acute or chronic inflammatory rash marked by itching

and redness that is the result of cutaneous contact with a specific
allergen or irritant.
True
False

6. A contusion is a bruise or hemorrhage with a break in the skin.

True
False

7. Once a patient has been coded 042, you must use 795.71 or V08 as a
coexisting condition.
True
False

8. Septic shock can only occur when severe sepsis is present.

True
False

9. The peripheral nervous system consists of the nerves and ganglia

outside the brain and spinal cord.
True
False

10. You are to use Chapter 11 codes only on the maternal record, never on
the record of a newborn.
True
False

Part 2 Multiple Choice

For the following questions, choose the best answer from the choices provided.
Each item is worth 0.5 points.

11. Infectious and parasitic diseases are generally caused by

a(n) _____.
a. fungus
b. virus
c. animal parasite agent
d. all of the above

0205502LB03A-29-13 29-25
Medical Coding and Billing Specialist

12. Which is a correct statement regarding burns? _____

a. You should assign multiple burns codes even when the location of the
burn is documented.
b. The site of the burn is indicated with the fourth digit.
c. Code burns individually to the greatest extent possible.
d. Sequence burns from the lowest to highest degree.

13. Which stage of pressure ulcers is identified by necrosis extending

through the skin to the underlying muscle? _____
a. Stage II
b. Stage IV
c. Stage I
d. Stage III

14. Chapter 15 of the Tabular List contains codes that pertain to _____.
a. the mortality and morbidity of the mother
b. only the baby’s records
c. only the mother’s records
d. all of the above

15. Which is not a true statement of sepsis? _____

a. Septicemia is a form of sepsis.
b. Sepsis occurs when there is a breakdown of local defense barriers.
c. If the physician documents streptococcal sepsis, you will code 038.0
and 995.91.
d. Coding streptococcal sepsis requires only one code.

16. Which is a true statement of rheumatoid arthritis? _____

a. Onset may be abrupt with simultaneous inflammation in multiple joints
or gradual, with progressive joint involvement.
b. RA is characterized by recurrent inflammation of the synovial joints and
related structures.
c. It is a chronic systemic disease.
d. All of the above

17. Which is not a true statement of the vertebral column? _____

a. There are seven cervical vertebrae numbered C1 through C7.
b. There are 12 thoracic vertebrae numbered T1 through T12.
c. There are seven lumbar vertebrae numbered L1 through L7.
d. There are five fused sacral vertebrae numbered S1 through S5.

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18. The term in situ _____.

a. describes tumor cells that are undergoing malignant changes but
are still confined to the site of origin without invasion of surrounding
normal tissue
b. can “classify by site certain histomorphologically well-defined neoplasms”
whose subsequent behavior “cannot be predicted from the present appearance”
c. describes cells that do not invade adjacent structures or spread to distant
sites, but they might displace or exert pressure on adjacent structures
d. describes the transfer of a disease from one organ or part to another
organ or part not directly connected with it

19. Mental, Behavioral and Neurodevelopmental Disorders (290-319) focus

on _____.
a. psychoses
b. neurotic, personality and other nonpsychotic mental disorders
c. intellectual disabilities
d. all of the above

20. Which is part of the upper limb? _____

a. Tibia
b. Clavicle
c. Femur
d. Fibula

21. Self-inflicted poisoning is classified as _____.

a. a suicide attempt
b. an accident
c. an assault
d. undetermined

22. _____ fractures are the result of the bone structure weakening by a
pathological process, such as occurs with osteoporosis and neoplasms.
a. Stress
b. Traumatic
c. Pathological
d. All of the above

23. Intellectual disabilities can be classified as _____.

a. first degree, second degree or third degree
b. mild, moderate, severe, profound or unspecified
c. chronic or acute
d. first stage, second stage or third stage

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Medical Coding and Billing Specialist

24. Which is not a true statement of the nervous system? _____

a. The brain, spinal cord, nerves and ganglia comprise the nervous system.
b. It regulates almost every activity in the body.
c. The nervous system consists of the brain and spinal cord only.
d. The central and peripheral nervous systems comprise the nervous system.

25. Which condition is found in subcategory 744.2, Other specified

anomalies of the ear? _____
a. Bat ear
b. Organ of Corti
c. Polyotia
d. Absence of external ear

26. An open fracture may be termed as _____.

a. comminuted
b. compound
c. greenstick
d. impacted

27. Supplementary Classification of Factors Influencing Health Status and

Contact with Health Services (V codes) are used for _____.
a. sick people
b. those with a resolving disease
c. unconfirmed diagnoses
d. external causes

28. Which is not a true statement of acute rheumatic fever? _____

a. Rheumatic fever usually appears weeks after the person has experienced
untreated or inadequately treated strep throat or scarlet fever.
b. Symptoms of rheumatic fever include fever, joint pain, lesions of the
heart, abdominal pain, rash or nodules on the skin and chorea.
c. Rheumatic fever is a febrile disease mainly occuring in the elderly.
d. This condition could lead to rheumatic heart disease.

29. The ICD-9-CM presumes a cause-and-effect relationship between

hypertension and chronic kidney disease, so you should begin
with the three-digit code _____.
a. 403 Hypertensive chronic kidney disease
b. 404 Hypertensive heart and chronic kidney disease
c. 402 Hypertensive heart failure and 585 Chronic kidney disease
d. 401 Essential hypertension

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 V Codes, E Codes and ICD-9-CM Coding Practicum

30. Acute respiratory infections include _____.

a. the common cold
b. pneumonia
c. influenza
d. all of the above

31. Which is a true statement of pneumonia? _____

a. Bacterial pneumonia is treated with antibiotics.
b. Antibiotics will not be effective for viral pneumonia.
c. Determining a viral or bacterial cause for the pneumonia may be
difficult, in which case antibiotics will be prescribed to treat the condition
in case it is bacterial.
d. All of the above

32. _____ is an inflammation of the serous membrane of the lungs and the
lining of the thoracic cavity.
a. Pleurisy
b. Empyema
c. Pneumothorax
d. Atelectasis

33. Gastric ulcers are those of the _____.

a. small intestine
b. esophagus
c. stomach
d. duodenum

34. Hernias “with obstruction” can be specified as _____.

a. incarcerated
b. strangulated
c. irreducible
d. all of the above

35. _____ is an inflammation of the tissue folds around the nail.

a. Felon
b. Paronychia
c. Onychia
d. None of the above

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Medical Coding and Billing Specialist

36. _____ is an inflammation of the urinary bladder.

a. A urinary tract infection
b. Cystitis
c. Pyelonephritis
d. Calculus

37. Which is not a true statement of the male reproductive system? _____
a. The reproductive duct system includes the epididymis, the ductus
deferens and the urethra.
b. The accessory glands include the seminal vesicle, the prostate gland and
the bulbourethral gland.
c. The external organs of the male reproductive system include the penis
and the scrotum.
d. The only internal portions of the male reproductive system are the
penis and the scrotum.

38. The leakage that might occur upon sneezing, laughing, coughing,
sudden movement or lifting is termed _____.
a. stress incontinence
b. genital prolapse
c. endometriosis
d. none of the above

39. Codes V27.0 through V27.9 include _____.

a. an outcome of delivery code for the newborn’s records
b. codes that are used on subsequent records for the mother when a
delivery has occurred
c. an outcome of delivery code for every maternal record when a delivery
has occurred
d. all of the above

40. Current medical conditions that did not exist before the pregnancy and
more than likely will not exist after the pregnancy are termed _____.
a. gestational
b. temporary
c. transient
d. both a and c

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 V Codes, E Codes and ICD-9-CM Coding Practicum

Part 3 Diagnostic Coding

Read the following scenarios. Use your ICD-9-CM to assign the accurate diagnosis
code(s). Verify final digits within the Tabular List and double-check your answers.
Each code is worth 2 points.

41. Term birth, living male, cesarean delivery, with hemolytic disease due to
ABO incompatibility. Code for the baby’s record.

_____________________________

_____________________________

42. Type 2 diabetic polyneuropathy, without insulin use

____________________________

____________________________

43. Traumatic rupture of the abdominal aorta secondary to a cut in the

anterior abdominal wall

____________________________

____________________________

44. Patient presents with 1st-degree burn of lower leg and 2nd-degree
burns of left foot, estimated 7% of total body surface.

____________________________

____________________________

____________________________

45. Elderly primigravida, term delivery, spontaneous, of living female

infant. Code for mother’s records.

____________________________

____________________________

46. Severe sunburn of face, neck and shoulders

_____________________________

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Medical Coding and Billing Specialist

47. Syncope due to adverse effect of the prescribed dosage of

antidepressant medication

_____________________________

_____________________________

48. Normal, full-term female, spontaneous delivery at the hospital, with

congenital left hip subluxation. Code for baby’s records.

_____________________________

_____________________________

49. Anemia due to blood loss from chronic gastric ulcer

_____________________________

_____________________________

50. Accessory fifth digit, right foot

_____________________________

51. Pneumonia due to fungus

_____________________________

_____________________________

52. Benign prostatic hypertrophy with urinary retention and incontinence

_____________________________

_____________________________

_____________________________

53. Severe manic depressive disorder, recurrent manic episode

_____________________________

54. Unintentional overdose of sleeping pills

_____________________________

_____________________________

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 V Codes, E Codes and ICD-9-CM Coding Practicum

55. Polyneuropathy in sarcoidosis

_____________________________

_____________________________

56. Premature delivery, frank breech presentation, single female liveborn.

Code mother’s record.

_____________________________

_____________________________

_____________________________

57. Bone atrophy due to infection

_____________________________

58. BURN CLINIC SCENARIO

SUBJECTIVE
A 25-year-old presents to the wound care clinic for care for burns to his left forearm.
The burn was sustained 1 week ago after he spilled boiling water at home. This is a
2nd-degree burn of the left forearm with the TBSA being 1.5%.

OBJECTIVE
Patient is here today for a dressing change. The existing dressing is removed,
and the wound is examined. The wound appears to be healing nicely with new
granulation in the wound. The wound is gently cleaned, and new sterile dressings
are applied.

ASSESSMENT
A 2nd-degree forearm burn with TBSA of 1.5%.

PLAN
No anesthesia was used during today’s visit, and the patient tolerated the
procedure with little pain. He is to return to the clinic in one week for additional
treatment and evaluation.

_____________________________

_____________________________

_____________________________

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Medical Coding and Billing Specialist

59. EMERGENCY ROOM SCENARIO

HISTORY OF PRESENT ILLNESS
The patient is a 20-year-old female with an 8-year history of IV heroin abuse. On the day of
admission, she appeared in the emergency department complaining of shortness of breath, chills
and fever.

PHYSICAL EXAMINATION
Blood pressure: 94/50. Pulse: 160. Respirations: 52 and labored with bilateral rhonchi.
Temperature: 100.8 ºF. Numerous petechiae on the lower extremity were noted. Jugular venous
distention was noted. The GI exam showed a tender liver.

DATABASE
EKG showed a right axis deviation and sinus tachycardia. The chest x-ray showed multiple
pulmonary opacities with a right upper lobe cavitation. Platelets 9000, hemoglobin 9.1,
hematocrit was 27.9, WBCs 10,000.

IMPRESSION
Due to progressive respiratory failure, the patient was intubated prior to admission. The patient
was diagnosed with acute renal failure and was placed in the ICU. The patient also has bacterial
endocarditis due to a staphylococcal infection and was started on triple antibiotics.

_____________________________

_____________________________

_____________________________

_____________________________

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 Medical Coding and Billing Specialist
Mail-in Quiz 29
1. Fill in your student ID and your course code below.
For School Use Only:
STUDENT ID NUMBER COURSE CODE Grade: ___________
2. Be sure your name and address are filled in below.
3. Transfer your answers to this cover sheet.

U.S. Career Institute CD-2

NAME
2001 Lowe Street
ADDRESS
Fort Collins, CO 80525
CITY STATE ZIP

This Space for Instructor Use  Fold on dotted line

Part 1 True or False

1. __________

2. __________

3. __________

4. __________

5. __________

6. __________

7. __________

8. __________

9. __________

10. __________

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Medical Coding and Billing Specialist

Part 2 Multiple Choice

11. __________ 26. __________

12. __________ 27. __________

13. __________ 28. __________

14. __________ 29. __________

15. __________ 30. __________

16. __________ 31. __________

17. __________ 32. __________

18. __________ 33. __________

19. __________ 34. __________

20. __________ 35. __________

21. __________ 36. __________

22. __________ 37. __________

23. __________ 38. __________

24. __________ 39. __________

25. __________ 40. __________

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 V Codes, E Codes and ICD-9-CM Coding Practicum

Part 3 Diagnostic Coding

41. _____________________________

_____________________________

42. _____________________________

_____________________________

43. _____________________________

_____________________________

44. _____________________________

_____________________________

_____________________________

45. _____________________________

_____________________________

46. _____________________________

47. _____________________________

_____________________________

48. _____________________________

_____________________________

49. _____________________________

_____________________________

50. _____________________________

51. _____________________________

_____________________________

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Medical Coding and Billing Specialist

52. _____________________________

_____________________________

_____________________________

53. _____________________________

54. _____________________________

_____________________________

55. _____________________________

_____________________________

56. _____________________________

_____________________________

_____________________________

57. _____________________________

58. _____________________________

_____________________________

_____________________________

59. _____________________________

_____________________________

_____________________________

_____________________________

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 V Codes, E Codes and ICD-9-CM Coding Practicum

Congratulations!
You have completed Lesson 29.

Drive
Terrific
n t !
Quality h me
l i s
o mp
A c c Learn
ing
Skillful

Do not wait to receive the results of your Quiz

before you move on.

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Medical Coding and Billing Specialist

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 Lesson 30

The Future of
Health Care

 Step 1 Learning Objectives for Lesson 30

 When you have completed the instruction in this lesson, you will be trained to do the following:
 Discuss important trends in the electronic health record.

 Differentiate between encoders and autocoding.

 Summarize the pros and cons of electronic coding.

 Explain key concerns with remote coding.

 Step 2 Lesson Preview

 From experimental drugs and cutting-edge procedures to computers and the Internet,
health care is changing. From the operating room to the front office, every level of
medicine is undergoing a revolution. Why? What’s driving this change? Technology!
Technology is rewriting not only the rules of what is necessary, but what is possible.

In this lesson, you’ll look at how technology is shaping the future of health care. We’ll
focus on trends in electronic health records and examine what they mean for the
medical coding and billing specialist. You’ll learn about new and upcoming coding tools,
such as encoders and computer-assisted coding. You’ll also learn about the possibility of
working from home with Web-based coding.

Coding, billing and health care are changing. Understanding those changes will help
prepare you for success in the years to come.

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Medical Coding and Billing Specialist

 Step 3 Technology and Health Care: Today

 The goal of medicine is quality patient care. The
backbone of patient care is health information
management. Transcriptionists, coders, billers
and administrators keep the gears of our health
system spinning. Without them, providers wouldn’t
get paid; medical files couldn’t be located; and the
system would back up like a traffic jam.

Healthcare professionals, like yourself, are the

unsung heroes of health care. They make sure
Without health information management,
the provider has the medical record when she’s
the system would back up like a traffic jam.
examining the patient. They make sure the patient
doesn’t overpay for services, supplies and advice.
They keep an eye out to make sure the diagnosis,
the procedure and the bill all match. All in all, they
manage the massive amount of information needed
by the healthcare industry.

In the past, a medical record was a thick paper file containing

notes on all of your visits. Hospitals and physician offices
maintained hundreds and thousands of these files which took
up a lot of space and time. More importantly, files at one
hospital could not easily be shared with another hospital. This
was not only a matter of distance. Different providers often
used different record formats and filing systems. When the
healthcare industry was smaller, this was not a big deal. But
now, with health care booming, patients, providers, insurance
companies and the government all realize the drawbacks of the
old paper system.

The healthcare industry is in the middle of a major shift. On

one front they are slowly converting from paper medical files to
In the past, a medical
electronic health records. Top to bottom they are learning to use
record was a thick paper file
computers in health information management.
containing notes on all
of the patient’s visits. Health information exchange (HIE) is the transmission of
healthcare-related data among facilities, health information
organizations and government agencies according to national
standards.1 The goal of HIE is to provide safe, timely, efficient and
effective access to and retrieval of patient information for providers.

The Institute of Medicine (IOM) originally created the term CPR (computer-based
patient record) to describe the computerized version of a medical record. The IOM
defined the CPR as “an electronic patient record that resides in a system specifically
designed to support users by providing accessibility to complete and accurate data,”
with other uses, as well (IOM, 1997).

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 The Future of Health Care

In 2003, the IOM report established eight core functions that a computer-based
patient record should be capable of performing.2

1. Health Information and Data. The IOM determined that the electronic
health record should contain the same items that are found in the paper chart,
including problem lists, medications and test results. In addition, the IOM
further stated that it should be a well designed interface to enable the provider
to review the information efficiently.
2. Result Management. This function refers to accessing information easily
when and where it is needed. The focus should be on availability, convenience,
reliability and ease of use. The provider should be able to access lab or x-ray
results any time and from anywhere.
For example, Bonnie had severe pain in the bottom side of her heel for the past
two days. The pain is localized to a single location. After exam, the provider has
an x-ray taken to rule out a fracture or tumor. Bonnie has the x-ray taken onsite
and returns to the exam room. Her provider returns and pulls the image up on
her computer. The provider determines there is no sign of a fracture or mass, but
suspects a bone spur is causing the pain. Bonnie is provided symptomatic care
and is advised that a radiologist will review the x-ray as well, so she’ll be called
the next day to confirm the diagnosis.
In this case, the electronic health record allowed the provider to import the x-ray.
However, the level of access should be considered as well. For instance, the dietitian
and pharmacist do not require the same level of access to a patient record.
3. Order Management. Computerized entry and storage of data on all medications,
tests and other services is an important function of a computer-based patient
record. Computerized provider order entry (CPOE) refers to any system in
which clinicians directly enter medication orders (and, increasingly, tests and
procedures) into a computer system, which then transmits the order directly
to the pharmacy.3 The advantages of CPOE include standardized, legible and
complete orders, which will reduce medical errors.
4. Decision Support. This function of the electronic health record will alert providers
and patients to vaccines, screenings and or preventative measures. In addition,
it provides warnings and reminders to assist providers in making the decision in
patient care. Decision support can aid in: drug interactions/prescriptions/prevention,
detection of disease outbreaks, evidence-based guidelines, etc.4
5. Electronic Communications and Connectivity. This function focuses on
patient safety and quality of care. It allows multiple providers in multiple setting
to communicate and coordinate care.
6. Patient Support. Studies have found that home monitoring and educational
materials are directly related to improving the control of a chronic illness, such
as diabetes.

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Medical Coding and Billing Specialist

7. Administrative Processes. Providing better, timelier services to patients

also helps the efficiency of a healthcare organization. Electronic health records
also assist with billing and claims management. The provider can immediately
validate insurance eligibility, as well as obtain authorizations. This function
results in more timely payments and less paperwork.
8. Reporting and Population Health Management. Computer-based patient
records provide a standardized system for reporting requirements for safety and
quality that are necessary for state, federal and local entities.

 Step 4 Electronic Health Records

 When the IOM suggested the key functions in 2003, it also established the term
electronic health record for this format. Let’s look at the alternative terms and
requirements of an electronic health record.

Electronic medical record, or EMR, is another description that is widely used for
this type of record. In hospital or office settings, EMR often refers to entire systems
that are based on document imaging, or electronic document management systems as
a whole. However, a more accurate term for the actual electronic record is electronic
health record, or EHR. The health information management field generally
recognizes the distinction between EMR and EHR as the degree of interoperability
that each offers. For our purposes, an EHR is defined as follows, according to
the Health Information Technology for Economic and Clinical Health (HITECH)
component of the American Recovery and Reinvestment Act (ARRA) of 2009:

A qualified EHR “includes patient demographics and clinical health information, and
has the capacity to provide clinical decision support; support physician order entry;
capture and query information relevant to health care quality; and exchange electronic
health information with and integrate such information from other sources.”5

Certified EHR technology “gives assurance to purchasers and other users that an
EHR system or module offers the necessary technological capability, functionality
and security to help them meet the meaningful use criteria. Certification also helps
providers and patients be confident that the electronic health IT products and
systems they use are secure, can maintain data confidentially and can work with
other systems to share information.”6

Meaningful use generally describes the ability to demonstrate quality

improvement through the use of EHRs. However, HITECH identifies three base
requirements for meaningful use:
 Use of certified or qualified EHR technology.
 Electronic exchange of health information.
 Use of EHR in reporting on clinical and other quality measures.7

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 The Future of Health Care

The Certified Commission for Health Information Technology (CCHIT) is recognized

by the U.S. Department of Health and Human Services as the entity to certify that
EHRs support meaningful use.

To ensure meaningful use, data comparability standards are necessary. Data

comparability standards make certain the meaning of a term is consistent across
all users. Standard vocabulary helps achieve data comparability. Until recently,
the specific vendor that developed the EHR software established most vocabularies.
However, HITECH requirements demand the use of controlled vocabulary to allow
for electronic exchange of health information. Controlled vocabulary means that
a specific set of terms in the EHR’s data dictionary must be used.

Providers may use different terms that mean the same thing. For instance, one
provider may document a heart attack, while another indicates an MI, and still
another notes a myocardial infarction. While these terms mean the same thing
to a cardiologist, they are entirely different to a computer. Without standard
terminology, it’s difficult to gather and retrieve information for research. Controlled
vocabulary allows users to index, store and retrieve information from an EHR.

The National Committee on Vital and Health Statistics (NCVHS) was asked
to recommend a national standard for vocabulary use in an EHR. The NCVHS
recommended that the federal government use the following “core set” of terminologies:8
 SNOMED CT—Systematized Nomenclature of Medicine - Clinical Terms

 LOINC—Logical Observation Identifiers Names and Codes

 RxNorm—federal drug terminologies

SNOMED CT presents data in a completely machine-readable format. While the

ICD coding database was designed for billing and reimbursement, SNOMED CT is
meant to organize the contents of a medical record to capture, encode and use data
for clinical care of patients and research. Due to the controlled vocabulary, SNOMED
CT can increase quality of care because it allows more accurate descriptions of a
patient’s medical issues in words physicians understand and doesn’t cross into the
administrative interpretations of diagnosis codes that are more familiar to coding staff.9

Health Level Seven (HL7) develops specifications for electronic healthcare

information. HL7’s mission is to increase the effectiveness and efficiency of
healthcare information.

HL7 standards identify types of errors and corrections in an electronic medical

record. HL7 has created computer messages to communicate corrections to different
computer systems. Let’s take a look at a couple of scenarios:

1. To create an addendum: Author dictates additional information as an addendum

to a previously transcribed document. A new document is transcribed. This
addendum has its own unique document ID that is linked to the original
document via the parent ID. Addendum document notification is transmitted.
This creates a composite document.

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Medical Coding and Billing Specialist

2. To correct errors that were discovered in the original health document that
haven’t been made available for patient care: Errors, which need to be corrected
are discovered in a document. The original document is edited, and an edit
notification is sent.10
One variation of the EHR is the personal health record (PHR), which is medical
information that the patient maintains. The PHR puts control in the consumer’s
hands. Instead of being a tool for the provider, the health record will become a tool
for the patient. In the future, people will have more responsibility for their own
well-being. Insurance companies are not the only ones pushing for a shift from
doctor as repairman to doctor as coach. Many people see the benefits of healthy
living and preventative medicine. The fitness and nutrition industry is growing.
So is interest in alternative medicines such as acupuncture and chiropractics.
Knowledge is power. Taking personal responsibility for your own health is the first
step in the fight against death, disease and aging. Personal health records will be
valuable weapons in this fight.

Now, you’ll learn about different types of Internet connections and networks.

 Step 5 Access the Internet and the Web

from a Computer
 OK, you have a computer and a Web browser; you’re viewing Web sites left and
right. But how exactly does it happen that these Web pages appear in your browser?

The Internet does not exist in one location. It exists in shared locations between
hundreds of millions of computers, servers and networks. For example, Erik in
Denmark may publish the photographs he took on his recent trip to Thailand. Xing
Mao in China may publish statistics on the ratios of female and male children that
families in the United States adopt. And Gabriela in Chile may publish a daily blog
(short for Web log, which is like an online diary) that describes her life in South
America, including sales information for the handmade products from her alpaca,
sheep and goat farm.

So where is all of this information? Well, remember that each of these Web pages is
published on the World Wide Web, which exists on the Internet. You, Erik, Xing Mao
and Gabriela can view these Web pages—and all the others that people everywhere
write—anytime you want, as long as you have access to the Internet.

Before you learn about the computer network, let’s look at the language of the
Internet. Many know that HTML (Hypertext Markup Language) was designed
to display data and is the most widely used language for Web-based documents. A
document using HTML contains embedded tags that provide guidance to HTML
viewers (usually called Web browsers) as to how to display the document and
connect it to other documents.10 HTML has its advantages and disadvantages:

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 The Future of Health Care

Advantages Disadvantages
Linkability—data is hyperlinked, letting you Intelligibility—limited in how well data
move from one site to another knows itself
Simplicity—it’s easy to learn and to display Adaptability—limited in data changes in
response to environmental changes
Portability—it’s portable over networks, Maintainability—limited in ease of data
operating systems and languages maintenance

Basically, the HTML format is not interoperable, which means that data cannot be
shared across organizations. EHRs don’t just “contain” or transmit information, they
also compute with it—for example, a qualified EHR will not merely contain a record
of a patient’s medications or allergies, it will also automatically check for problems
whenever a new medication is prescribed and alert the clinician to potential
conflicts. HTLM is unable to compute. XML (Extensible Markup Language) was
designed to overcome this limitation, which improves the functionality of the Web by
letting you identify your information in a more accurate, flexible and adaptable way.
XML is the language of EHRs.

The Computer Network

To access the information on the Internet, your computer must be part of a network.
A network is a system of computers and/or servers, printers and databases that
communications lines connect. All computers, servers, printers or databases connected
to one network are called nodes. All nodes have the means to share information and
communicate with one another.

Types of Networks

Networks exist so that different computers can rely on one another to perform
functions like storing, sending and retrieving information.

Network Diagram

server To access the information on

(node) the Internet, your computer
must be part of a network.

personal personal personal personal

computer computer computer computer
(node) (node) (node) (node)

printer (node)

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Medical Coding and Billing Specialist

There are four basic types of computer networks.

1. Client/Server Network—One or more computers (called clients) are connected

to one another and to a central computer or mainframe (called a server). We’ll
talk about servers in more detail in a moment, but first, let’s look at an example
of a client/server network.

A manufacturing plant in Michigan makes engines for hybrid vehicles. All of the
conveyer belts that move the engines throughout the plant are connected to a
central computer. Based on signals from other, smaller computers at different
workstations, the central computer knows how fast or how slow to run the
conveyer belts. It even knows when to turn the conveyer belts off if there is an
emergency or a breakdown in one area of the plant. These computers are on a
client/server network.

2. Peer-to-Peer Network—Two or more computers are connected to one another

and share information without the presence of a server.

Let’s say that Cody and Ben are college roommates, and both young men use Mac
Book laptops with iTunes and iPods. Cody has a great collection of more than
four thousand listening hours of Classic Rock, Pop and Indie Rock music, while
Ben has a substantial amount of rare Jazz and Blues recordings. They’ve decided
to set up a peer-to-peer network so they can easily share music files without
violating copyright laws.

3. LAN Network—LAN stands for local area network. Such a network consists
of one or more computers in a home or office that are connected to one another
and a server. They are a self-contained network with a gateway or link to the
Internet. Let’s study an example.

Martin is a freelance graphic designer and avid photographer who runs his
own business from the comforts of his home office. Martin uses three printers, a
copier, a laptop computer and a large desktop computer with a huge flat screen
monitor for his work. Meanwhile, his wife owns a laptop, and his daughters
share a desktop computer and printer in their bedroom. Martin and his family’s
computers all have Internet access, and they are connected to one server (and
one back up server) that he keeps in the basement. This arrangement is an
example of a LAN.

4. WAN Network—WAN stands for wide area network. Such a network

consists of two or more LANs in several different buildings that are connected
to one another.

An example of a WAN might be an international broadcasting company that has

offices in the United States, Canada, Panama, Brazil, Great Britain, Germany,
France, Spain, Poland, Saudi Arabia, Sri Lanka, South Korea, the Philippines
and New Zealand. Each of these offices contain multiple LANs, but the LANs
are connected into a larger WAN to facilitate faster e-mail communication and to
share full access to photographic images and video footage database files.

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 The Future of Health Care

Servers

A server is a data resource that other computers access for information. Some
people call a server a host computer, and that analogy works well when you
think about the functions a server performs. For example, when you host a party,
you make introductions among your guests. You refill the drinks, make important
announcements and manage the music or overall atmosphere at the party. A server
operates in much the same way. Since the server is a host to the computers attached
to its network, the server relays information, transfers files, delivers programs and
awaits and fulfills the requests of its client computers.

 Step 6 Electronic Coding

 Electronic coding uses computers to speed up the coding process. As technology
develops, more and more computers will be used in coding. While this may alter some
of your responsibilities, it is important to know everything you’re learning in this
course. With more computers helping in the health information department, medical
coding and billing specialists will act more as editors to the computer’s coding.

There are several different levels of electronic coding: encoder programs, computer-assisted
coding and NLP autocoding. Let’s take a look at each.

Encoder Programs
An encoder is an interactive computer program that helps you assign codes. With this
program, the user inserts a keyword and then selects different sections, subsections,
headings, subheadings and code listings related to that keyword. Think of this type of
encoder as a computer-version of your ICD-9-CM, ICD-10-CM, CPT and the HCPCS
manual, all rolled into one. This encoder assists you in navigating your code quickly and
with the click of a button. In Pack 5, you will receive a demonstration CD-ROM of one of
these encoders. You’ll also receive a supplement showing you how to use it like a pro.

However, using an encoder program doesn’t mean you don’t need to be familiar
with coding rules and the manuals. You need to have a clue to locate the accurate
code! For many coders, the encoder program is more useful as a verification tool. For
example, let’s say you’re looking up the code for abdominal pain. If you use this as
the basis for your encoder search, you are likely to get so many potential codes that
you’ll have a hard time narrowing it down to the right one.

One of the benefits of using encoders is efficiency. And when it comes to coding,
efficiency equals money.

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Medical Coding and Billing Specialist

Look at the following example. Search for Abdominal pain, and the encoder program
retrieves several code categories.

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 The Future of Health Care

Let’s narrow down our search. If you already know that the code for abdominal pain
is 789.0, you can use the encoder to fine-tune your search. Here’s an example using
the encoder in that way.

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Medical Coding and Billing Specialist

If you are unsure of the correct fifth digit to use for RLQ (right lower quadrant), just
scroll down the list like the example below. Do you see the code 789.03? Great!

Computer-assisted Coding
After encoders, the next level of technology is
computer-assisted coding (CAC). CAC uses a computer
to assign an actual code. Whereas an encoder
determines the best code, a computer-assisted program
is programmed to pick codes itself. The computer
can do this in one of two ways: by using inputted
information or by finding the diagnosis and procedure
in the chart itself. Let’s examine how each of these
methods work.

In addition to improving accuracy,

computer-assisted programs can shorten
the time it takes to code a chart.

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 The Future of Health Care

The most common automated coding systems require a user to input data. The user
will read a medical chart and figure out the diagnoses and the procedures. Next she
will type this information into the computer-assisted program. The computer uses
logic and coding rules programmed into its memory to code the diagnoses and the
procedures. Of course, this system isn’t perfect. CAC programs are not advanced
enough to handle rules which can be interpreted in several different ways. As you’ve
learned with your ICD-9-CM coding, not all codes are black and white. However, CAC
software can draw the user’s attention to any codes it has trouble with. This is where
you, the medical coding and billing specialist, come in!

The second type of CAC software is much more advanced than the first.
Some medical providers use a software called natural language
processing (NLP), which can read and translate English. Instead
of having to input the diagnoses and procedures to be coded, the
entire medical chart can be uploaded into the NLP autocoder.
This program will read the chart, pick out the diagnoses and
procedures, and then assign the appropriate code.

But how accurate is it? Today, NLP technology is not advanced

enough to rival the accuracy of an experienced, human
coder. However, NLP software is getting better. Instead of
using a rigid set of rules to program the computer-assisted
coding, NLP uses complex statistical methods to predict how
an experienced human would code the information. Using
statistics gives NLP autocoders flexibility, as well as the
ability to improve. Like a human, the more the NLP software
translates and codes, the better it gets. Like standard
computer-assisted programs, NLP software can alert the Natural language processing
user when it is unsure about a code. In fact, because it uses can translate doctor reports
statistics, it can say exactly how unsure it is. into medical codes.

But NLP technology isn’t perfect. There is more to coding than just connecting the
dots, as you now know. While the NLP autocoding software companies are touting
their programs as the next wave in health information management, not everyone is
so sure. Many providers are skeptical and question just how valid the programs are.
It doesn’t matter how fast the programs are if they aren’t accurate enough.

What does computer-assisted coding mean for the medical coding and billing
specialist? Will they be replaced by computers? The answer is no, although
there will be some changes. Computers will eventually take over much of the
manual work of assigning simple codes and transcribing basic medical reports.
Computer-assisted coders will zip through the easy and routine codes. However,
healthcare professionals will still be needed to tackle all of the challenging reports
which stump the computer. And with medicine constantly evolving, there will always
be plenty of exciting and new charts to code.

In addition, coders may be responsible for managing these programs and their coded
data. Coders will be in charge of quality-control, security, and monitoring the regular
additions, deletions, and changes to the code sets. It is an exciting time to be a coder.
You’re getting in on the first wave of a whole new system!

0205502LB03A-30-13 30-13
Medical Coding and Billing Specialist

 Step 7 Web-based Coding

 One of the advantages of medical coding and billing is that you may work from
home. While three years of experience are generally required for coding, more and
more coders telecommute. As providers become used to managing information
electronically, you can expect less-experienced coders to work from home.

With Web-based coding, also called remote coding, the provider scans or captures
the medical record, encrypts the file so unauthorized people can’t read it and e-mails it
to a secure computer server. The chart is given a digital certificate. A digital certificate
is like an electronic lock. Only the person with the right electronic key—such as a
password—can open it. When a chart is stored on the server and assigned to a medical
coder, it is given a digital certificate that only that medical coder can open.

You can either work with the medical chart while it is saved on the server, or you
may download the file and work with it after disconnecting from the Internet.
The latter is more secure because there are less opportunities for hackers to
break in and view the information. Once you’re done, you e-mail the coded chart
back to the server and delete the information from your computer.

Here’s an example of how remote or Web-based coding may look like through an
Internet connection.

Source: http://www.medquist.com/products/coding/autodemo/609_MedQuist_CodeRunner.htm

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 The Future of Health Care

Security is a very important issue for

Web-based coders. This is especially true with
all of the security guidelines mandated by
HIPAA. In addition to encryption and digital
certificates, physical security is important. The
computer you use for home coding shouldn’t
be used for non-work activities (like Internet
shopping). The system should be protected
by a password, and others should not have
access to it. Some remote coding companies and
agreements stipulate that management can
Security is a very important
inspect the home office at any time to ensure
issue for Web-based coders.
that security is being maintained.

On the following page is an example of an agreement between an employer

and a remote coder. As you can see, computer set-up and security measures
must be in place before the employee can initiate coding from home.

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Medical Coding and Billing Specialist

SAMPLE HOME CODER CONFIDENTIALITY POLICY

Confidentiality and Non-Disclosure Agreement
As an employee / contracted employee affiliated with the (name of organization), I understand that I must
maintain the confidentiality of any and all data and information to which I have access. Organizational
information that may include, but is not limited to, financial, patient identifiable, employee identifiable,
intellectual property, financially non-public, contractual, of a competitive advantage nature, and is from any
source or in any form (i e paper, magnetic or optical media, conversations, film, etc ), may be considered
confidential. The value and sensitivity of information is protected by law and by the strict policies of (name of
organization). The intent of these laws and policies is to assure that confidential information will remain
confidential through its use, only as a necessity to accomplish the organization’s mission.

As a condition to receiving a computer sign-on code and allowed access to a system and/or being
granted authorization to access any form of confidential information identified above, I agree to comply
with the following terms and conditions:

1. My Sign-On Code is equivalent to my LEGAL SIGNATURE and I will not disclose this code to
anyone or allow anyone to access the system using my Sign-On Code.
2. I am responsible and accountable for all entries made and all retrievals accessed under my Sign-On
Code, even if such action was made by me or by another due to my intentional or negligent act or
omission. Any data available to me will be treated as confidential information.
3. I will not attempt to learn or use another’s Sign-On Code.
4. I will not access any on-line computer system using a Sign-On Code other than my own.
5. I will not access or request any information for which I have no responsibility.
6. If I have reason to believe that the confidentiality of my User Sign-On Code/password has been
compromised, I will immediately notify (responsible party) by calling the helpdesk at (helpdesk
phone number).
7. I will not disclose any confidential information unless required to do so in the official capacity of
my employment or contract. I also understand that I have no right or ownership interest in any
confidential information.
8. While signed on, I will not leave a secured computer application unattended.
9. I will comply with all policies and procedures and other rules of (name of organization) relating to
confidentiality of information and sign-on codes.
10. I understand that my use of the system may be periodically monitored to ensure compliance with this
agreement.
11. I agree not to use the information in any way detrimental to the organization and will keep all such
information confidential.
12. I will not disclose protected health information or other information that is considered proprietary,
sensitive, or confidential unless there is a need to know basis.
13. I will limit distribution of confidential information to only parties with a legitimate need in
performance of the organization’s mission.
14. I agree that disclosure of confidential information is prohibited indefinitely, even after termination of
employment or business relationship, unless specifically waived in writing by an authorized party.
15. This agreement cannot be terminated or canceled, nor will it expire.
16. I will report to the Corporate Compliance Hotline any unauthorized access or use of confidential
information. I understand that my reporting is confidential and that I will remain anonymous.

I further understand that if I violate any of the above terms, I may be subject to disciplinary action, including
discharge, loss of privileges, termination of contract, legal action, or any other remedy available to (name of
organization).

User’s Name ________________________________ Date ______________________________

(Please Print)

User’s Signature: _____________________________ Department: ________________________

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 The Future of Health Care

However, if you follow the rules, Web-based coding can give you a lot of flexibility
and save you the daily commute. (And that’s something to look forward to!) Of
course, not everyone likes working at home. Many coders and billers prefer the
socialization of working in an office. Some like the easy access to tech support and
reference material. It is also easier to ask physicians questions and communicate
with your manager. You have to decide which work setting works best for you!

 Step 8 Practice Exercise 30-1

 Determine five trends in the technology of health care.

1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

4. ___________________________________________________________________

5. ___________________________________________________________________

 Step 9 Review Practice Exercise 30-1

 Check your answers with the Answer Key at the back of this book. Correct any
mistakes you may have made.

 Step 10 Lesson Summary

 Computers are revolutionizing health care. With electronic health records,
they’re helping ensure consistent, quality care. With personal health records,
computers empower people to manage their own health. On the coding front,
they improve accuracy with encoders and speed with computer-assisted coding
(CAC) programs. Natural language programming (NLP) will free coders up to
focus more on managing medical information. The Internet allows more and
more people to work safely and efficiently from home. All in all, computers are
the future. The change to a fully-electronic health information system will be
slow. But it will come, and health care will never be the same. And you will be
on the front line of this exciting technology!

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Medical Coding and Billing Specialist

 Step 11 Mail-in Quiz 30

 Follow the steps to complete the Quiz.

a. Be sure you’ve mastered the instruction and the Practice Exercises that
this Quiz covers.
b. Mark your answers on your Quiz. Remember to check your answers with the
lesson content.
c. When you’ve finished, transfer your answers to the Scanner Answer Sheet
included. Use only blue or black ink on your Scanner Answer Sheet.
d. Important! Please fill in all information requested on your Scanner Answer
Sheet or when submitting your Quiz online.
e. Submit your answers to the school via mail, fax or, to receive your grade
immediately, submit your answers online at www.uscareerinstitute.edu.

Mail-in Quiz 30
Choose the best answer from the choices provided. Each item is worth 5 points.

1. The Institute of Medicine (IOM) originally created the term CPR

(computer-based patient record), and it also established _____ core
functions that a computer-based patient record should perform.
a. eight
b. seven
c. six
d. five

2. Healthcare professionals may do which of the following? _____

a. Make sure diagnoses and procedures match
b. Apply codes for patient encounters
c. Process billing for patient encounters
d. All of the above

3. A medical record that the patient has access to and control over is
called a(n) _____.
a. PPO
b. HMO
c. PVP
d. PHR

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 The Future of Health Care

4. According to the IOM, a computer-based patient record should include

______, which can aid in drug interactions/prescriptions/prevention,
detection of disease outbreaks and evidence-based guidelines.
a. Order Management
b. Patient Support
c. Decision Support
d. Result Management

5. Electronic coding _____.

a. uses computers to speed up the coding process
b. is decreasing in popularity
c. is against HIPAA regulations
d. is illegal

6. A(n) _____ is an interactive coding program that works like a computerized

version of the ICD-9-CM, ICD-10-CM, CPT and HCPCS manuals.
a. digital coder
b. encoder
c. CAC (computer-assisted coding)
d. NLP autocoder

7. A(n) _____ is a coding program that automatically assigns codes once

the coder inputs the diagnoses and procedures.
a. digital coder
b. encoder
c. CAC (computer-assisted coding)
d. NLP autocoder

8. A(n) _____ is a coding program that reads medical charts, picks out the
diagnoses and procedures and automatically assigns codes.
a. digital coder
b. encoder
c. CAC (computer-assisted coding)
d. NLP autocoder

9. Web-based coding requires _____.

a. a computer
b. an Internet connection
c. a password to access secure information
d. all of the above

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Medical Coding and Billing Specialist

10. Which of the following is the most secure solution for Web-based
coding? _____
a. Opening and working with encrypted files while online from your
family computer
b. Opening and working with encrypted files while online from your
work-only computer
c. Downloading then working with encrypted files offline from your
family computer
d. Downloading then working with encrypted files offline from your
work-only computer

11. What is one of the base requirements for meaningful use? ______
a. Certified or qualified EHR technology
b. Paper based exchange of health information
c. Use of ICD vocabulary
d. A firm understanding of EHR software development

12. A _____ EHR gives assurance that the criteria for meaningful use have
been met.
a. qualified
b. valued
c. certified
d. national

13. Which is a true statement of controlled vocabulary? ____

a. It is needed to assign the correct ICD code.
b. Controlled vocabulary is needed to index, store and retrieve
EHR information.
c. Providers need controlled vocabulary to interact with nurses.
d. It is needed for proper reimbursement from third-party payers.

14. A computerized version of a medical record is termed _____.

a. encoded
b. encrypted
c. CPR
d. EDMS

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 The Future of Health Care

15. The encoder program ____.

a. assigns codes based on the uploaded dictation
b. will put medical coding and billing specialists out of work
c. assists in locating the accurate code efficiently
d. should only be used by experienced medical coding and billing specialists

16. Which is a true statement about natural language processing? _____

a. It uses a rigid set of rules to determine the accurate code.
b. NLP software will alert the coder when it’s unsure of a code.
c. NLP technology always works correctly.
d. NLP will eventually replace the medical coding and billing specialist.

17. ____ presents data in a completely machine-readable format.

a. NLP
b. CAC
c. Encoder
d. SNOMED CT

18. The core set of terminologies include _____.

a. NLP, LOINC and RxNorm
b. CAC and NLP
c. SNOMED CT and CAC
d. SNOMED CT, LOINC and RxNorm

19. What is a drawback of the paper medical record? _____

a. They take up a lot of space.
b. They are easily shared among hospitals.
c. The record formats are consistent.
d. It is expensive to transition to EHRs.

20. _____ is very important to Web-based coders.

a. Efficiency
b. Commuting
c. Security
d. Increased pay

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Medical Coding and Billing Specialist

Endnotes
1
“Health information exchange (HIE).” Search Health IT. May 10, 2012. Web. 18 June 2012.
2
“Core Functions of an EHR.” EHR Scope. July 14, 2009. Web. 18 June 2012.
3
“Computerized Provider Order Entry.” Agency for Healthcare Research and Quality. Web. 18 June 2012.
4
“Core Functions of an EHR.” EHR Scope. July 14, 2009. Web. 18 June 2012.
5
“Frequently Asked Questions on HITECH Provider Incentives Under Medicare.” Minnesota e-Health, 18 June,
2009. Web. 10 April 2012.
6.
“Overview.” Centers for Medicare & Medicaid Services, 9 April, 2012. Web. 10 April 2012.
7.
“Frequently Asked Questions on HITECH Provider Incentives Under Medicare.” Minnesota e-Health, 18 June,
2009. Web. 10 April 2012.
8.
Lumpkin, John. “Letter to The Honorable Tommy G. Thompson.” 5 Nov., 2003. Web. 10 April 2012.
9.
Fluckinger, Don. “SNOMED CT will be coming to EHR systems and patient records near you.” TechTarget, n.d.
10 April 2012.
10.
“XML vs. HTML: A Publishing Comparison.” United States Bureau of the Census’s Statistical Compendia
Branch. July 19, 2002. Web. 18 June 2012.

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 The Future of Health Care

Dedication ʀ Professional ʀ Gain ʀ EXTRAORDINARY

Happiness ʀ Nice ʀ Progress ʀ Superb ʀ Fantastic
TRIUMPH ʀ Incredible ʀ Victory ʀ Accurate ʀ Growth
Remarkable ʀ Nicely done ʀ Study ʀ %ULOOLDQW
ADVANCEMENT ʀ First-rate ʀ Splendid ʀ Strategy
i

Detailed ʀ Fine ʀ Winning ʀ Tremendous ʀ Great

Perseverance ʀ Work ʀ impressive ʀ Astonishing
Drive ʀ PERSISTENCE ʀ Consistent ʀ Skillful
Determination ʀ Quality ʀ TerriÀc ʀ Resolution
ACCOMPLISHMENT ʀ Super ʀ Learning

You’ve completed Pack 3!

Do not wait to receive the results of your Quiz
before you move on.

0205502LB03A-30-13 30-23
Medical Coding and Billing Specialist

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 Pack 3

Introduction
Medical Coding to
and
Medical
Billing Terminology:
Specialist
Word Parts
Answer Key
Lesson 21
Practice Exercise 21-1
1. Inquiry c. Asking an insurance company about a delayed claim

2. Resubmission a. Sending in a claim a second time with “SECOND BILLING”

written at the top

3. Narrative explanation d. A further description of a procedure or other

information on a claim

4. State insurance commissioner b. Oversees the state insurance regulations

Practice Exercise 21-2

1. Credit is the merchant’s acceptance of your promise to pay later for goods or services
you receive immediately.

2. The document listing your credit history is called your credit report.

3. The document listing your credit history is important to potential creditors who are
considering giving you credit.

4. Late payments, bankruptcies and defaults are called negative credit information.

5. People referred to as credit risks end up paying higher interest rates.

6. If a debtor fails to live up to his credit agreement, his account is delinquent.

7. If a check bounces, the bank returns the check with the letters NSF stamped across
the check.

8. The person filing the action in small claims court is the plaintiff.

9. The person being sued in small claims court is the defendant.

10. The defendant’s employer withholds a percentage of the defendant’s pay each month
and sends the money to the creditor. In order to do this, a legal document called a(n)
order of garnishment is required.

0205502LB03A-AK-13
Medical Coding and Billing Specialist

Lesson 22
Practice Exercise 22-1

1. Certified Coding Specialists (CCS) are skilled professional coders with solid
experience classifying medical data from patient records.

2. AHIMA is recognized as one of the industry’s most active and influential advocates
in Congress.

3. The Certified Billing and Coding Specialist (CBCS) exam focuses on converting
a medical procedure and diagnosis into specific codes for submitting a claim for
reimbursement.

4. The AMA speaks out on important issues like patient rights and the health of
the nation.

5. The CPC exam tests the student on diagnostic and procedural codes, compliance
and reimbursement policies.

6. In addition to coding the diagnosis and procedures for outpatient settings, the CPC-H
exam also focuses on reimbursement procedures, such as fee updates and how to
complete the UB-04.

7. The goal of the AAPC is to provide education, recognition, and certification for
physician-practice procedural coders.

8. CCS-P coders have in-depth experience with diagnostic and procedural codes. They also
are experts in health information documentation.

Practice Exercise 22-2

1. BillingInsider AAPC

2. CPT Assistant AMA

3. Coding Clinic AHA

4. Coder’s Desk Reference for Diagnoses OptumInsight

5. Communities of Practice AHIMA

6. Coder’s Desk Reference for Procedures OptumInsight

7. Coding Edge AAPC

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 Pack 3—Answer Key

Lesson 23
Practice Exercise 23-1
1. The ICD originally was used to track b. mortality statistics.

2. The Bertillon Classification of Causes of Death was first used in the Americas in which
country? c. Mexico

3. In 1946, the United Nations gave the responsibility for the ICD to the a. World Health
Organization.

4. The United States adopted the International Classification of Diseases, 9th Revision,
Clinical Modification (ICD-9-CM), based on the ICD-9, in d. 1979.

5. The ICD-9-CM consists of a(n) d. tabular list, alphabetical index and

procedure alphabetic index and tabular list.

6. A primary use of medical codes is to communicate to the insured the reason

for a patient’s medical visit.

7. Medical coding is a statistics-gathering tool for research, grants and

financial analysis.

8. The ICD-9-CM outdated codes produce inaccurate and limited data.

Practice Exercise 23-2

1. The ICD-9-CM for Physicians manual is divided into b. two volumes.

2. The ICD-9-CM for Physicians manual lists d. diagnostic codes.

3. Main terms appear in b. boldface type.

4. Information in parentheses following a main term is called a(n) a. nonessential

modifier, and it has no effect on selecting the correct code.

5. The d. Tabular List uses a numerical index cross-referenced with diseases and
injuries according to the anatomical system affected and/or etiology.

6. A medical coder must assign the most c. specific code possible—a subcategory,
if it is available.

7. Supplementary classifications might be a. V or E codes.

8. b. Residual classifications ensure that there is always a code for every disease.

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Medical Coding and Billing Specialist

Practice Exercise 23-3

1. When a diagnosis is not principal and is used alone, you should code the
b. underlying disease first.

2. ICD-9-CM coding uses the INCLUDES and EXCLUDES instructional notes to

assist coders in assigning diagnostic codes at the c. highest level.

3. Notes, when found in the Index to Diseases, are a. boxed and italicized.

4. In the multiple coding instruction, “Use additional code, if desired,” you should
ignore the words d. if desired.

5. NEC means b. not elsewhere classifiable.

6. NOS means c. not otherwise specified.

7. A note might instruct you to assign a(n) d. fifth digit because subclassification
categories are available.

Practice Exercise 23-4

1. An object not naturally occurring in the human body is a. a foreign body.

2. A late effect is defined as a(n) d. residual effect after the acute phase of an illness
or injury has ended.

3. c. Study of tumors Appendix A

4. d. Was deleted in 2004 Appendix B

5. a. Drug classification Appendix C

6. e. Job-related accidents Appendix D

7. b. Three-digit categories Appendix E

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 Pack 3—Answer Key

Practice Exercise 23-5

1. The first step in ICD-9-CM coding is to identify all c. main terms.

2. Assign codes to their b. highest level of specificity.

3. When you assign codes for an outpatient or inpatient diagnosis, the

c. principal diagnosis is the first code sequenced.

4. Do not assign codes for a. rule-out statements in outpatient settings.

5. Urinary tract infection

Main term infection
Subterm urinary (tract)
Coding pathway infection, urinary (tract)

6. Recurrent appendicitis
Main term appendicitis
Subterm recurrent
Coding pathway appendicitis, recurrent

7. Unknown pain in leg

Main term pain
Subterm leg
Coding pathway pain, leg

8. Diaper rash
Main term rash
Subterm diaper
Coding pathway rash, diaper

9. Loss of appetite Alternative Answer:

Main term appetite loss
Subterm lack or loss appetite
Coding pathway appetite, lack or loss loss, appetite

10. Inflammation of the sinus

Main term inflammation
Subterm sinus
Coding pathway inflammation, sinus

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Medical Coding and Billing Specialist

11. High-altitude sickness

Main term sickness
Subterm altitude
Coding pathway sickness, altitude

12. Vision examination

Main term examination
Subterm vision
Coding pathway examination, vision

13. Ear examination

Main term examination
Subterm ear
Coding pathway examination, ear

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 Pack 3—Answer Key

Lesson 24
Practice Exercise 24-1

1. 005.9
Coding pathway: Poisoning, food 005.9
Tabular List description: 005.9 Food poisoning, unspecified

2. 011.04
Coding pathway: Tuberculosis, pulmonary, infiltrative 011.0 
Fifth-digit subclassification: 4= tubercle bacilli not found (in sputum) by
microscopy, but found by bacterial culture
Tabular List description: 011.04 Tuberculosis of lung, infiltrative, tubercle
bacilli not found (in sputum) by microscopy, but found by bacterial culture.

3. 021.9
Coding pathway: Fever, rabbit 021.9
Alternative pathway: Rabbit fever 021.9
Tabular List description: 021.9 Unspecified tularemia

4. 033.9
Coding pathway: Pertussis—see also Whooping cough 033.9
Tabular List description: 033.9 Whooping cough, unspecified organism

5. 038.3
Coding pathway: Septicemia, Bacteroides 038.3
Tabular List description: 038.3 Septicemia due to anaerobes
Note: use additional code for SIRS but SIRS or sepsis not noted so no additional
code needed.

6. 042 136.3
Principal coding pathway: AIDS 042
Principal Tabular List description: 042 Human immunodeficiency
virus [HIV] disease
Coexisting coding pathway: Pneumonia, Pneumocystis (carinii) 136.3
Coexisting Tabular List description: 136.3 Pneumocystosis

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Medical Coding and Billing Specialist

7. Coding pathway: Septicemia, gram-negative 038.40

Coding pathway: SIRS (systemic inflammatory response syndrome)
due to, infectious process 995.91

1500 MED LINK HMO

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1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) X (SSN or ID) (SSN) (ID) 52100900602
2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
BLOOMQUIST REBECCA 06 25 1997 M F X BLOOMQUIST DICK
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
409 YORKSHIRE Self Spouse Child x Other SAME
CITY STATE 8. PATIENT STATUS CITY STATE
YOURTOWN CO Single x Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
80001 (970) 5555875 Employed
Student x Student ( )
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER
NONE WBHMO
a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX
MM DD YY

YES X NO 03 10 1967 M X F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
MM DD YY
M F YES X NO WILTON BOOKSTORE
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES X NO MED LINK HMO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES X NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED SIGNATURE ON FILE DATE 05 08 XX SIGNED SIGNATURE ON FILE

14. DATE OF CURRENT 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD ILLNESS (First symptom) OR
YY GIVE FIRST DATE MM DD YY MM DD YY MM DD YY
INJURY (Accident) OR
05 08 XX
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM DD YY MM DD YY
17b. NPI FROM TO
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
YES X NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. 038 . 40 3. .
23. PRIOR AUTHORIZATION NUMBER
2. 995 . 91 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

05 08 XX 05 08 XX 23 99283 12 187 00 1 NPI

2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
900 00 9000 X X YES NO $ 187 00 $ 0 00 $ 187 00
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #
INCLUDING DEGREES OR CREDENTIALS (970) 5552222
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.
JAMES HAHNS MD JAMES HAHNS MD
800 MEDICAL COURT 800 MEDICAL COURT
YOURTOWN CO 80000 YOURTOWN CO 80000
a. 0405674390 b. a. 0405674390 b.
SIGNED DATE

AK-8 0205502LB03A-AK-13
 Pack 3—Answer Key

Practice Exercise 24-2

1. 049.9
Coding pathway: Encephalitis, viral 049.9
Tabular List description: 049.9 Unspecified non-arthropod-borne viral diseases
of central nervous system

2. 050.2
Coding pathway: Varioloid 050.2
Tabular List description: 050.2 Modified smallpox

3. 055.2
Coding pathway: Measles, with, otitis media 055.2
Tabular List description: 055.2 Postmeasles otitis media

4. 056.9
Coding pathway: Measles, German 056.9
Tabular List description: 056.9 Rubella without mention of complication

5. 066.40
Coding pathway: Fever, West, Nile 066.40
Tabular List description: 066.40 West Nile fever, unspecified

6. 071
Coding pathway: Rabies 071
Tabular List description: 071 Rabies

7. 074.3
Coding pathway: Disease, hand, foot and mouth 074.3
Tabular List description: 074.3 Hand, foot and mouth disease

8. 088.81
Coding pathway: Disease, Lyme 088.81
Alternative pathway: Lyme disease 088.81
Tabular List description: 088.81 Lyme disease

9. 057.0
Coding pathway: Disease, fifth 057.0
Tabular List description: 057.0 Erythema infectiosum [fifth disease]

0205502LB03A-AK-13 AK-9
Medical Coding and Billing Specialist

Practice Exercise 24-3

1. 093.9
Coding pathway: Syphilis, cardiovascular (early) 093.9
Tabular List description: 093.9 Cardiovascular syphilis, unspecified

2. 098.11
Coding pathway: Cystitis, gonococcal (acute) 098.11
Tabular List description: 098.11 Gonococcal cystitis (acute) upper

3. 110.4
Coding pathway: Infection, fungus, foot 110.4
Tabular List description: 110.4 Dermatophytosis, Of foot

4. 114.0
Coding pathway: Fever, desert 114.0
Tabular List description: 114.0 Primary coccidioidomycosis (pulmonary)

5. 126.9
Coding pathway: Disease, hookworm 126.9
Tabular List description: 126.9 Ancylostomiasis and necatoriasis, unspecified

6. 133.0
Coding pathway: Scabies (any site) 133.0
Tabular List description: 133.0 Scabies

AK-10 0205502LB03A-AK-13
 Pack 3—Answer Key

7. Coding pathway: Human immunodeficiency virus, infection V08

Coding pathway: Hepatitis, viral, type C, chronic 070.54
Note: “Probable” pneumocystis carinii pneumonia is an unconfirmed diagnosis.

1500 MOUNTAIN STATES

1801 SW VINE ST
HEALTH INSURANCE CLAIM FORM
DENVER, CO 80217
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) X (SSN or ID) (SSN) (ID) 520007777
2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
FOX BENJAMIN 12 02 1970 M X F SAME
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
1227 COMET DRIVE APT 6B Self X Spouse Child Other

CITY STATE 8.PATIENT STATUS CITY STATE

SPRINGTOWN CO Single X Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
80002 (970) 5551001 Employed X Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER
NONE 120
a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX
MM DD YY

YES X NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
MM DD YY
M F YES X NO PHILCO GAS
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES X NO MOUNTAIN STATES
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES X NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED SIGNATURE ON FILE DATE 06 14 XX SIGNED SIGNATURE ON FILE

14. DATE OF CURRENT 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD ILLNESS (First symptom) OR
YY GIVE FIRST DATE MM DD YY MM DD YY MM DD YY
INJURY (Accident) OR
06 14 XX
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM DD YY MM DD YY
17b. NPI FROM TO
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
YES X NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. V08 . 3. .
23. PRIOR AUTHORIZATION NUMBER
2. 070 . 54 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

06 14 XX 06 14 XX 23 99213 12 63 00 1 NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
900 00 9000 X X YES NO $ 63 00 $ 0 00 $ 63 00
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #
INCLUDING DEGREES OR CREDENTIALS (970) 5552222
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.
JAMES HAHNS MD JAMES HAHNS MD
800 MEDICAL COURT 800 MEDICAL COURTT
YOURTOWN CO 80000 YOURTOWN CO 80000
a. 0405674390 b. a. 0405674390 b.
SIGNED DATE

0205502LB03A-AK-13 AK-11
Medical Coding and Billing Specialist

Practice Exercise 24-4

1. 191.0
Coding pathway: Glioma, specified site NEC – see Neoplasm, by site, malignant
Neoplasm table: Neoplasm, cerebrum, Malignant, Primary 191.0
Tabular List description: 191.0 Malignant neoplasm of brain, Cerebrum, except
lobes and ventricles

2. 198.3 162.9
Coding pathway: Carcinoma - see also Neoplasm, by site, malignant
Neoplasm table: Neoplasm, brain NEC, Malignant, Secondary 198.3
Tabular List description: 198.3 Secondary malignant neoplasm, Brain and
spinal cord
Neoplasm table: Neoplasm, lung, Malignant, Primary 162.9
Coexisting Tabular List description: 162.9 Malignant neoplasm of trachea,
bronchus and lung, Bronchus and lung, unspecified

3. 201.20
Coding pathway: Hodgkin’s, sarcoma 201.2 
Alternative pathway: Sarcoma, Hodgkin’s 201.2 
Fifth-digit subclassification: 0 = unspecified site, extranodal and solid organ sites
Tabular List description: 201.20 Hodgkin’s sarcoma, unspecified site, extranodal
and solid organ sites

4. 216.4
Neoplasm table: Neoplasm, scalp, Benign 216.4
Tabular List description: 216.4 Benign neoplasm of skin, Scalp and skin of neck

5. 218.9
Coding pathway: Fibromyoma, uterus 218.9
Tabular List description: 218.9 Leiomyoma of uterus, unspecified

6. 151.5
Coding pathway: Adenocarcinoma – see also Neoplasm, by site, malignant
Neoplasm table: Neoplasm, gastric – see Neoplasm, stomach
New pathway: Neoplasm, stomach, lesser curvature, Malignant, Primary 151.5
Tabular List description: 151.5 Malignant neoplasm of stomach, Lesser
curvature, unspecified
Note: the type of biopsy helps determine the site of the neoplasm.

AK-12 0205502LB03A-AK-13
 Pack 3—Answer Key

Practice Exercise 24-5

1. 244.0
Coding pathway: Hypothyroidism, postsurgical 244.0
Tabular List description: 244.0 Acquired hypothyroidism,
Postsurgical hypothyroidism

2. 250.33
Coding pathway: Diabetic, coma, hypoglycemia 250.3 
Alternative pathway: Hypoglycemia, coma, diabetic 250.3 
Fifth-digit subclassification 3 = type 1, uncontrolled
Tabular List description: 250.33 Diabetes with other coma,
type 1, uncontrolled

3. 252.01
Coding pathway: Hyperparathyriodism, primary 252.01
Tabular List description: 252.01 Primary hyperparathyroidism

4. 256.4
Coding pathway: Polycystic, ovary, ovaries 256.4
Tabular List description: 256.4 Polycystic ovaries

5. 274.00
Coding pathway: Gouty, arthropathy 274.00
Alternative pathway: Arthropathy, gouty 274.00
Tabular List description: 274.00 Gouty arthropathy

6. 282.62
Coding pathway: Disease, sickle cell, with, crisis 282.62
Tabular List description: 282.62 Sickle-cell disease, Hb-SS disease with crisis

7. 289.4
Coding pathway: Syndrome, big spleen 289.4
Alternative pathway: Big spleen syndrome 289.4
Tabular List description: 289.4 Hypersplenism

0205502LB03A-AK-13 AK-13
Medical Coding and Billing Specialist

8. Coding pathway: Hypercalcemia 275.42

Coding pathway: Cancer –see also Neoplasm, by site, malignant
Neoplasm table: Neoplasm, thyroid, Malignant, Primary 193
1500 Country Group
PO BOX 324
HEALTH INSURANCE CLAIM FORM
SPRINGTOWN, CO 80002
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) X (SSN or ID) (SSN) (ID) 560001113
2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
SCHMIDT BONNIE 06 25 1952 M F X SAME
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED
1810 BLUEGRASS DRIVE Self X Spouse Child Other

CITY STATE 8. PATIENT STATUS

SPRINGTOWN CO Single Married X Other

ZIP CODE TELEPHONE (Include Area Code)

Full-Time Part-Time
80002 (970) 5559041 Employed X Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER
SCHMIDT RICHARD 208
a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX
MM DD YY

635007213 YES X NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
MM DD YY

09 15 1952 M X F YES X NO KAIN GRAPHICS

c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
USAF YES X NO COUNTRY GROUP
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
CHAMPVA X YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED SIGNATURE ON FILE DATE 10 17 XX SIGNED SIGNATURE ON FILE

14. DATE OF CURRENT 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD ILLNESS (First symptom) OR
YY GIVE FIRST DATE MM DD YY MM DD YY MM DD YY
INJURY (Accident) OR
10 17 XX
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM DD YY MM DD YY
17b. NPI FROM TO
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
YES X NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. 275 . 42 3. .
23. PRIOR AUTHORIZATION NUMBER
2. 193 . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

10 17 XX 10 17 XX 11 99213 12 63 00 1 NPI 0810998051

2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
66 6000600 X X YES NO $ 63 00 $ 0 00 $ 63 00
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #
INCLUDING DEGREES OR CREDENTIALS (970) 5553344
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.
FRONT RANGE FAMILY CARE FRONT RANGE FAMILY CARE
1800 CIRCLE COURT 1800 CIRCLE COURT
YOURTOWN CO 80000 YOURTOWN CO 80000
a. 0881099885 b. a. 0881099885 b.
SIGNED DATE

AK-14 0205502LB03A-AK-13
 Pack 3—Answer Key

Lesson 25
Practice Exercise 25-1

1. 291.0
Coding pathway: Delirium, alcoholic 291.0
Tabular List description: 291.0 Alcohol withdrawal delirium

2. 295.20
Coding pathway: Stupor, catatonic 295.2 
Fifth-digit subclassification 0 = unspecified
Tabular List description: 295.20 Schizophrenic disorders, Catatonic
type, unspecified

3. 298.1
Coding pathway: Psychosis, hysterical, acute 298.1
Tabular List description: 298.1 Other nonorganic psychoses, Excitative
type psychosis

4. 300.3
Coding pathway: Disorder, obsessive-compulsive 300.3
Alternative pathway: Obsessive-compulsive 300.3
Tabular List description: 300.3 Obsessive-compulsive disorders

5. 307.1
Coding pathway: Anorexia, nervosa 307.1
Tabular List description: 307.1 Anorexia nervosa

6. 312.32
Coding pathway: Kleptomania 312.32
Tabular List description: 312.32 Disorders of impulse control, not elsewhere
classified, Kleptomania

7. 317
Coding pathway: Subnormality, mental, mild 317
Tabular List description: 317 Mild intellectual disabilities

0205502LB03A-AK-13 AK-15
Medical Coding and Billing Specialist

8. Coding pathway: Disorder, bipolar 296.80

1500 MEDICAID
PO BOX 1461
HEALTH INSURANCE CLAIM FORM
DENVER, CO 80203
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) X (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID) 521003333
2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
REYNOLDS KAMI 06 25 1997 M F X
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED
4575 DIXON COURT APT 7 Self Spouse Child Other

CITY STATE 8. PATIENT STATUS

YOUNGSTOWN CO Single X Married Other

ZIP CODE TELEPHONE (Include Area Code)

Full-Time Part-Time
80004 (970) 5556996 Employed
Student X Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX
MM DD YY

YES X NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
MM DD YY
M F YES X NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES X NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED SIGNATURE ON FILE DATE 05 01 XX SIGNED

14. DATE OF CURRENT 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD ILLNESS (First symptom) OR
YY GIVE FIRST DATE MM DD YY MM DD YY MM DD YY
INJURY (Accident) OR
05 01 XX
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM DD YY MM DD YY
17b. NPI FROM TO
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
YES X NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. 296 . 80 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

05 01 XX 05 01 XX 11 99213 1 63 00 1 NPI 0275695402

2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
99 0000009 X X YES NO $ 63 00 $ 0 00 $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #
INCLUDING DEGREES OR CREDENTIALS (970) 5551111
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.
MEDICAL CARE CENTER MEDICAL CARE CENTER
100 SOUTH MAIN 100 SOUTH MAIN
YOURTOWN CO 80000 YOURTOWN CO 80000
a. 0665544004 b. a. 0665544004 b.
SIGNED DATE

AK-16 0205502LB03A-AK-13
 Pack 3—Answer Key

Practice Exercise 25-2

1. 320.3
Coding pathway: Meningitis, staphylococcal 320.3
Tabular List description: 320.3 Staphylococcal meningitis

2. 330.1
Coding pathway: Disease, Tay-Sachs 330.1
Alternative pathway: Tay-Sachs, disease 330.1
Alternative pathway: Disease, Sachs (-Tay) 330.1
Tabular List description: 330.1 Cerebral lipidoses

3. 333.83
Coding pathway: Torticollis, spasmodic 333.83
Tabular List description: 333.83 Spasmodic torticollis

4. 342.11
Coding pathway: Hemiplegia, spastic 342.1 
Fifth-digit subclassification 1 = affecting dominant side
Tabular List description: 342.11 Spastic hemiplegia, affecting
dominant side

5. 345.11
Coding pathway: Epilepsy, grand mal 345.1 
Fifth-digit subclassification 1 = with intractable epilepsy
Tabular List description: 345.11 Generalized convulsive epilepsy, with
intractable epilepsy

6. 351.0
Coding pathway: Bell’s, palsy 351.0
Alternative pathway: Palsy, Bell’s 351.0
Tabular List description: 351.0 Bell’s palsy

0205502LB03A-AK-13 AK-17
Medical Coding and Billing Specialist

7. Coding pathway: Sclerosis, multiple 340

1500 BLUE CROSS OF WYOMING

PO BOX 456
HEALTH INSURANCE CLAIM FORM
CASPER, WY 82002
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) X (SSN or ID) (SSN) (ID) 641000000
2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
HARRISON CATHY 08 09 1967 M F X HARRISON TOM
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
2419 ZENDT DRIVE Self Spouse X Child Other SAME
CITY STATE 8.PATIENT STATUS CITY STATE
ANYTOWN CO Single Married X Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
80000 (970) 5552112 Employed X Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER
NONE GE54002
a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX
MM DD YY

YES X NO 08 02 1959 M X F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
MM DD YY
M F YES X NO FRONT RANGE AUTO SALES
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES X NO BLUE CROSS OF WYOMING
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES X NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED SIGNATURE ON FILE DATE 03 19 XX SIGNED SIGNATURE ON FILE

14. DATE OF CURRENT 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD ILLNESS (First symptom) OR
YY GIVE FIRST DATE MM DD YY MM DD YY MM DD YY
INJURY (Accident) OR
03 19 XX
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM DD YY MM DD YY

CAROLYN HOOPER MD 17b. NPI 0188123456 FROM TO

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
YES X NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. 340 . 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

03 19 XX 03 19 XX 11 99242 1 102 00 1 NPI 0267679942

2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
66 6000600 X X YES NO $ 102 00 $20 00 $ 82 00
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #
INCLUDING DEGREES OR CREDENTIALS (970) 5553344
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.
FRONT RANGE FAMILY CARE FRONT RANGE FAMILY CARE
1800 CIRCLE COURT 1800 CIRCLE COURT
YOURTOWN CO 80000 YOURTOWN CO 80000
a. 0881099885 b. a. b.
SIGNED DATE 0881099885

AK-18 0205502LB03A-AK-13
 Pack 3—Answer Key

Practice Exercise 25-3

1. 360.21
Coding pathway: Myopia, malignant 360.21
Tabular List description: 360.21 Progressive high (degenerative) myopia

2. 362.52
Coding pathway: Degeneration, macula, disciform 362.52
Tabular List description: 362.52 Exudative senile macular degeneration

3. 372.03
Coding pathway: Pink, eye 372.03
Tabular List description: 372.03 Acute conjunctivitis, Other
mucopurulent conjunctivitis

4. 376.32
Coding pathway: Hemorrhage, orbit 376.32
Tabular List description: 376.32 Orbital hemorrhage

5. 384.01
Coding pathway: Myringitis, bullous 384.01
Tabular List description: 384.01 Bullous myringitis

6. 386.00
Coding pathway: Disease, Meniere’s 386.00
Alternative pathway: Meniere’s disease, syndrome, or vertigo 386.00
Tabular List description: 386.00 Meniere’s disease, unspecified

7. 383.00
Coding pathway: Mastoiditis, acute 383.00
Tabular List description: 383.00 Acute mastoiditis without complications

0205502LB03A-AK-13 AK-19
Medical Coding and Billing Specialist

Practice Exercise 25-4

1. 392.9
Coding pathway: Chorea, rheumatic 392.9
Tabular List description: 392.9 Rheumatic chorea, Without mention of
heart involvement

2. 397.9
Coding pathway: Endocarditis, rheumatic 397.9
Tabular List description: 397.9 Rheumatic diseases of endocardium,
valve unspecified

3. 401.1
Coding pathway: Hypertension, benign 401.1
Tabular List description: 401.1 Essential hypertension, Benign

4. 405.99 255.0
Coding pathway: Hypertension, due to, Cushing’s disease
Unspecified 405.99
Tabular List description: 405.99 Secondary hypertension,
Unspecified, Other
Coding pathway: Disease, Cushing 255.0
Tabular List description: 255.0 Cushing’s syndrome

5. 410.01
Coding pathway: Infarction, myocardial, anterolateral 410.0 
Fifth-digit subclassification 1 = initial episode of care
Tabular List description: 410.01 Acute myocardial infarction, Of
anterolateral wall, initial episode of care

6. 403.91 585.6
Coding pathway: Hypertension, kidney, with, chronic kidney disease, stage V or
end stage renal disease, Unspecified 403.91
Tabular List description: 403.91 Hypertensive chronic kidney disease,
Unspecified, with chronic kidney disease stage V or end stage
renal disease
Tabular List 403 notes to identify the stage
Coding pathway: Disease, renal, end-stage 585.6
Tabular List description: 585.6 Chronic kidney disease
[CKD], End stage renal disease

AK-20 0205502LB03A-AK-13
 Pack 3—Answer Key

Practice Exercise 25-5

1. 416.0
Coding pathway: Hypertension, pulmonary, idiopathic,
Unspecified 416.0
Tabular List description: 416.0 Primary pulmonary hypertension

2. 426.13
Coding pathway: Phenomenon, Wenckebach’s, heart block 426.13
Alternative pathway: Wenckebach’s phenomenon, heart block 426.13
Tabular List description: 426.13 Other second degree
atrioventricular block

3. 440.20
Coding pathway: Arteriolosclerosis, extremities 440.20
Tabular List description: 440.20 Atherosclerosis of the
extremities, unspecified

4. 454.9
Coding pathway: Varicose, vein (lower extremity) 454.9
Tabular List description: 454.9 Asymptomatic varicose veins

5. 427.81
Coding pathway: Syndrome, sick, sinus 427.81
Tabular List description: 427.81 Sinoatrial node dysfunction

0205502LB03A-AK-13 AK-21
Medical Coding and Billing Specialist

Lesson 26
Practice Exercise 26-1

1. 466.0
Coding pathway: Bronchitis, pneumococcal, acute or subacute 466.0
Tabular List description: 466.0 Acute bronchitis

2. 473.0
Coding pathway: Sinusitis, maxillary 473.0
Tabular List description: 473.0 Chronic sinusitis, Maxillary

3. 482.84
Coding pathway: Disease, Legionnaires’ 482.84
Alternative Pathway: Legionnaires’ disease 482.84
Tabular List description: 482.84 Legionnaires’ disease

4. 493.20
Coding pathway: Bronchitis, asthmatic, chronic 493.2 
Fifth-digit subclassification 0 = status or exacerbation are not stated
Tabular List description: 493.20 Chronic obstructive asthma, unspecified

5. 518.82
Coding pathway: Syndrome, respiratory distress, adult, specified NEC 518.82
Tabular List description: 518.82 Other pulmonary insufficiency, not
elsewhere classified

6. 518.81
Coding pathway: Failure, respiration, acute 518.81
Tabular List description: 518.81 Other diseases of lung, Acute
respiratory failure

AK-22 0205502LB03A-AK-13
 Pack 3—Answer Key

Practice Exercise 26-2

1. 528.00
Coding pathway: Stomatitis, ulcerative 528.00
Tabular List description: 528.00 Stomatitis and mucositis, unspecified

2. 531.00
Coding pathway: Ulcer, prepyloric –see Ulcer, stomach
New pathway: Ulcer, stomach, acute, with, hemorrhage 531.0 
Fifth-digit subclassification 0 = without mention of obstruction
Tabular List description: 531.00 Gastric ulcer, Acute with hemorrhage, without
mention of obstruction

3. 532.71
Coding pathway: Ulcer, duodenum, chronic 532.7 
Fifth-digit subclassification 1 = with obstruction
Tabular List description: 532.71 Duodenal ulcer, Chronic without mention of
hemorrhage or perforation, with obstruction

4. 540.0
Coding pathway: Appendicitis, with, perforation, peritonitis (generalized), or
rupture 540.0
Tabular List description: 540.0 Acute appendicitis, With generalized peritonitis

5. 552.3
Coding pathway: Hernia, hiatal, with, obstruction (strangulated means
obstruction) 552.3
Tabular List description: 552.3 Diaphragmatic hernia with obstruction

6. 560.30
Coding pathway: Impaction, impacted, bowel, colon, rectum 560.30
Tabular List description: 560.30 Impaction of intestine, unspecified

7. 564.2
Coding pathway: Syndrome, dumping 564.2
Alternative pathway: Dumping syndrome (postgastrectomy) 564.2
Tabular List description: 564.2 Postgastric surgery syndromes

0205502LB03A-AK-13 AK-23
Medical Coding and Billing Specialist

8. 571.5
Coding pathway: Cirrhosis, liver 571.5
Tabular List description: 571.5 Cirrhosis of liver without mention of alcohol

9. 535.50 531.90 532.90

Coding pathway: Gastritis 535.5 
Fifth-digit subclassification 0 = without mention of hemorrhage
Tabular List description: 535.50 Unspecified gastritis and gastroduodenitis,
without mention of hemorrhage
Coding pathway: Ulcer, gastric – see Ulcer, stomach
New pathway: Ulcer, stomach, 531.9 
Fifth-digit subclassification 0 = without mention of obstruction
Tabular List description: 531.90 Gastric ulcer, Unspecified as acute or chronic,
without mention of hemorrhage or perforation, without mention
of obstruction
Coding pathway: Ulcer, duodenal 532.9 
Fifth-digit subclassification 0 = without mention of obstruction
Tabular List description: 532.90 Duodenal ulcer, Unspecified as acute or
chronic, without mention of hemorrhage or perforation, without mention
of obstruction

Practice Exercise 26-3

1. 250.40 581.81 V58.67

Coding pathway: Nephrosis, diabetic 250.4  [581.81]
250 Fifth-digit subclassification 0 = unspecified type, not stated as uncontrolled
Tabular List description: 250.40 Diabetes with renal manifestation, type II or
unspecified type, not stated as uncontrolled
Tabular List note: Use additional code, if applicable, for associated long-term
(current) insulin use V58.67
Tabular List description: 581.81 Nephrotic syndrome in diseases classified
elsewhere
Tabular List description: V58.67 Long-term (current) use of insulin

AK-24 0205502LB03A-AK-13
 Pack 3—Answer Key

2. 590.2
Coding pathway: Carbuncle, kidney 590.2
Tabular List description: 590.2 Renal and perinephric abscess

3. 595.0 041.49
Coding pathway: Cystitis, acute 595.0
Tabular List description: 595.0 Acute cystitis
Note: Use additional code to identify organism
Coding pathway: Infection, Escherichi coli 041.49
Tabular List description: 041.49 Other and unspecified Escherichia coli [E. coli]

4. 600.10
Coding pathway: Hard firm prostate 600.10
Tabular List description: 600.10 Nodular prostate without
urinary obstruction

5. 604.0
Coding pathway: Abscess, testicle – see Orchitis
New pathway: Orchitis, with abscess 604.0
Tabular List description: 604.0 Orchitis, epididymitis and
epididymo-orchitis with abscess

6. 610.2
Coding pathway: Fibroadenosis, breast (periodic) 610.2
Tabular List description: 610.2 Fibroadenosis of breast

7. 618.02
Coding pathway: Prolapse, vagina, paravaginal 618.02
Tabular List description: 618.02 Prolapse of vaginal walls without mention of
uterine prolapse, Cystocele, lateral

8. 626.0
Coding pathway: Amenorrhea 626.0
Tabular List description: 626.0 Absence of menstruation

0205502LB03A-AK-13 AK-25
Medical Coding and Billing Specialist

9. Coding pathway: Infection, urinary (tract) 599.0

Note: Use additional code to identify organism.
Coding pathway: Infection, Enterobacter aerogenes 041.85
1500 BLUE CROSS OF IOWA
PO BOX 1677
HEALTH INSURANCE CLAIM FORM
SIOUX CITY, IA 51102
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) X (SSN or ID) (SSN) (ID) 666006663
2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
JONES SAMUEL 05 19 1972 M X F SAME
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
3 HWY SOUTH Self X Spouse Child Other

CITY STATE 8.PATIENT STATUS CITY STATE

ANYTOWN CO Single Married Other X
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
80000 (970) 5551313 Employed X Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER
NONE VE001
a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX
MM DD YY

YES X NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
MM DD YY
M F YES X NO GREEN FINGER NURSERY
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES X NO BLUE CROSS OF IOWA
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES X NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED SIGNATURE ON FILE DATE 02 28 XX SIGNED SIGNATURE ON FILE

14. DATE OF CURRENT 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD ILLNESS (First symptom) OR
YY GIVE FIRST DATE MM DD YY MM DD YY MM DD YY
INJURY (Accident) OR
02 28 XX
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM DD YY MM DD YY
17b. NPI FROM TO
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
YES X NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. 599 . 0 3. .
23. PRIOR AUTHORIZATION NUMBER
2. 041 . 85 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

02 28 XX 02 28 XX 11 99213 12 63 00 1 NPI 0304851124

2.

02 28 XX 02 28 XX 11 81000 12 10 00 1 NPI 0304851124

3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
86 8000600 X X YES NO $ 73 00 $0 00 $ 73 00
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #
INCLUDING DEGREES OR CREDENTIALS (970) 5551834
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.
SPRINGTOWN CLINIC SPRINGTOWN CLINIC
1824 PARK AVENUE 1824 PARK AVENUE
SPRINGTOWN CO 80000 SPRINGTOWN CO 80000
a. 0304455166 b. a. 0304455166 b.
SIGNED DATE

AK-26 0205502LB03A-AK-13
 Pack 3—Answer Key

Practice Exercise 26-4

1. 633.20
Coding pathway: Pregnancy, ovarian 633.20
Tabular List description: 633.20 Ovarian pregnancy without
intrauterine pregnancy

2. 634.92
Coding pathway: Miscarriage – see Abortion, spontaneous
New pathway: Abortion, spontaneous, 634.9 
Fifth-digit subclassification 2 = complete
Tabular List description: 634.92 Spontaneous abortion, Without mention of
complication, complete

3. 641.13
Coding pathway: Pregnancy, complicated (by), placenta, previa, 641.1 
Fifth-digit subclassification 3 = antepartum condition or complication
Tabular List description: 641.13 Hemorrhage from placenta previa, antepartum
condition or complication

4. 643.03
Coding pathway: Hyperemesis, gravidarum 643.0 
Fifth-digit subclassification 3 = antepartum condition or complication
Tabular List description: 643.03 Mild hyperemesis gravidarum, antepartum
condition or complication

5. 651.01 V91.00 V27.2

Coding pathway: Delivery, twins 651.0 
Fifth-digit subclassification 1 = delivered, with or without mention of
antepartum condition
Tabular List description: 651.01 Twin pregnancy, delivered, with or without
mention of antepartum condition
Coding pathway: Gestation, multiple, placenta status, twin, unspecified number
of placenta, unspecified number of amniotic sacs V91.00
Tabular List description: V91.00 Twin gestation, unspecified number of
placenta, unspecified number of amniotic sacs
Coding pathway: Outcome of delivery, twins, both liveborn V27.2
Tabular List description: V27.2 Twins, both liveborn

0205502LB03A-AK-13 AK-27
Medical Coding and Billing Specialist

6. 654.21 V27.0
Coding pathway: Delivery, complicated (by), previous, cesarean delivery 654.2 
Fifth-digit subclassification 1 = delivered, with or without mention of
antepartum condition
Tabular List description: 654.21 Previous cesarean delivery, delivered, with or
without mention of antepartum condition
Coding pathway: Outcome of delivery, single, liveborn V27.0
Tabular List description: V27.0 Single liveborn

7. 664.21 V27.0
Coding pathway: Delivery, complicated (by), laceration, perineum, third degree
664.2 
Fifth-digit subclassification 1 = delivered, with or without mention of
antepartum condition
Tabular List description: 664.21 Third-degree perineal laceration, delivered,
with or without mention of antepartum condition
Coding pathway: Outcome of delivery, single, liveborn V27.0
Tabular List description: V27.0 Single liveborn

8. 673.24
Coding pathway: Pregnancy, complicated (by), embolism (pulmonary) 673.2 
Alternative pathway: Embolism, obstetrical (pulmonary) 673.2 
Fifth-digit subclassification 4 = postpartum condition or complication
Tabular List description: 673.24 Obstetrical blood-clot embolism, postpartum
condition or complication

9. 676.14
Coding pathway: Cracked nipple, puerperal, postpartum 676.1 
Fifth-digit subclassification 4 = postpartum condition or complication
Tabular List description: 676.14 Cracked nipple, postpartum condition
or complication

10. 650 V27.0

Coding pathway: Delivery, normal – see category 650
Tabular List description: 650 Normal delivery
Coding pathway: Outcome of delivery, single, liveborn V27.0
Tabular List description: V27.0 Outcome of delivery, Single liveborn

AK-28 0205502LB03A-AK-13
 Pack 3—Answer Key

Lesson 27
Practice Exercise 27-1

1. 680.0
Coding pathway: Boil, ear (any part) 680.0
Tabular List description: 680.0 Carbuncle and furuncle, Face

2. 692.71
Coding pathway: Sunburn 692.71
Tabular List description: 692.71 Contact dermatitis and other eczema,
Due to solar radiation, Sunburn

3. 692.84
Coding pathway: Eczema, due to specified cause – see Dermatitis, due to
New pathway: Dermatitis, due to, hair, animal (cat) (dog) 692.84
Tabular List description: 692.84 Contact dermatitis and other eczema, Due to
other specified agents, Due to animal (cat) (dog) dander

4. 695.4
Coding pathway: Lupus, erythematosus 695.4
Alternative pathway: Erythema, erythematous, lupus 695.4
Tabular List description: 695.4 Lupus erythematosus

5. 698.0
Coding pathway: Itch, perianal 698.0
Tabular List description: 698.0 Pruritus and related conditions, Pruritus ani

6. 704.00
Coding pathway: Baldness 704.00
Tabular List description: 704.00 Alopecia, unspecified

0205502LB03A-AK-13 AK-29
Medical Coding and Billing Specialist

7. 707.05 707.22 438.20

Coding pathway: Ulcer, pressure, buttock 707.05
Tabular List description: 707.05 Chronic ulcer of skin, Pressure ulcer, Buttock
Coding pathway: Ulcer, pressure, stage, II 707.22
Tabular List description: 707.22 Pressure ulcer stage II
Coding pathway: Late, effect, cerebrovascular disease, with, hemiplegia,
affecting, unspecified side 438.20
Tabular List description: 438.20 Late effects of cerebrovascular disease,
Hemiplegia/hemiparesis, Hemiplegia affecting unspecified side
Note: late effect is coded because the patient would not have the pressure sore
if not in a wheelchair. The patient is in the wheelchair because of the
hemiplegia which was caused by the cerebrovascular disease.

AK-30 0205502LB03A-AK-13
 Pack 3—Answer Key

8. Coding pathway: Paronychia, finger 681.02

Tabular List description: 681.02 Cellulitis and abscess of finger and toe, Finger,
Onychia and paronychia of finger

1500 MEDICARE
600 GRANT ST STE 600
HEALTH INSURANCE CLAIM FORM
DENVER, CO 80203
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
X (Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID) 501007319A
2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
EMMA SMITH 01 30 1930 M F x
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
1410 IRIS DRIVE Self Spouse Child Other

CITY STATE 8.PATIENT STATUS CITY STATE

MYTOWN CO Single Married Other X
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
80001 (970) 5555843 Employed
Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER
NONE
a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX
MM DD YY

YES X NO M F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
MM DD YY
M F YES X NO
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES X NO MEDICARE
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED SIGNATURE ON FILE DATE 07 12 XX SIGNED

14. DATE OF CURRENT 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD ILLNESS (First symptom) OR
YY GIVE FIRST DATE MM DD YY MM DD YY MM DD YY
INJURY (Accident) OR
07 12 XX
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM DD YY MM DD YY
17b. NPI FROM TO
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
YES X NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. 681 . 02 3. .
23. PRIOR AUTHORIZATION NUMBER
2. . 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

07 12 XX 07 12 XX 11 99212 1 50 00 1 NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
333 33 0003 X X YES NO $ 50 00 $ 0 00 $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #
INCLUDING DEGREES OR CREDENTIALS (970) 5551514
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.
SARAH DUNCAN MD SARAH DUNCAN MD
1414 SWALLOW STREET 1414 SWALLOW STREET
YOURTOWN CO 80000 YOURTOWN CO 80000

0205502LB03A-AK-13 AK-31
Medical Coding and Billing Specialist

Practice Exercise 27-2

1. 719.41
Coding pathway: Arthralgia—see also Pain, joint
New pathway: Pain, joint, shoulder 719.41
Tabular List description: 719.41 Other and unspecified disorders of joint, Pain
in joint, shoulder region

2. 722.0
Coding pathway: Hernia, intervertebral cartilage or disc – see Displacement,
intervertebral disc
New pathway: Displacement, intervertebral disc, cervical 722.0
Tabular List description: 722.0 Intervertebral disc disorders, Displacement of
cervical intervertebral disc without myelopathy

3. 722.91
Coding pathway: Calcification, disc, intervertebral, cervical 722.91
Tabular List description: 722.91 Intervertebral disc disorders, Other and
unspecified disc disorder, Cervical region

4. 724.2
Coding pathway: Pain, back, low 724.2
Tabular List description: 724.2 Other and unspecified disorders of back, Lumbago

5. 726.5
Coding pathway: Bursitis, hip 726.5
Tabular List description: 726.5 Peripheral enthesopathies and allied syndromes,
Enthesopathy of hip region

6. 727.03
Coding pathway: Trigger finger (acquired) 727.03
Tabular List description: 727.03 Other disorders of synovium, tendon, and
bursa, Synovitis and tenosynovitis, Trigger finger (acquired)

7. 728.0
Coding pathway: Myositis, infective 728.0
Tabular List description: 728.0 Disorders of muscle, ligament and fascia,
Infective myositis

8. 733.02
Coding pathway: Osteoporosis, idiopathic 733.02
Tabular List description: 733.02 Other disorders of bone and cartilage,
Osteoporosis, Idiopathic osteoporosis

AK-32 0205502LB03A-AK-13
 Pack 3—Answer Key

9. Coding pathway: Hypothyroidism 244.9

Coding pathway: Arthritis, rheumatoid 714.0
Coding pathway: Osteoporosis 733.00
1500 TRICARE
PO BOX 100502
HEALTH INSURANCE CLAIM FORM
FLORENCE, SC 29501 0502
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) X (Sponsor’s SSN) (Member ID #) (SSN or ID) (SSN) (ID) 352005515
2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
SCOTT JANET 11 11 1985 M F X SCOTT JAMES
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
HQ USAF SP PSC 5 Self Spouse X Child Other HQ USAF SP PSC 5
CITY STATE 8.PATIENT STATUS CITY STATE
ELLSWORTH AFB SD Single Married X Other ELLSWORTH AFB SD
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
57706 (605) 5556330 Employed X Student Student 57706 (605) 5556330
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER
NONE
a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX
MM DD YY

YES X NO 09 13 1985 M X F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
MM DD YY
M F YES X NO USAF
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES X NO TRICARE
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES X NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED SIGNATURE ON FILE DATE 08 20 XX SIGNED SIGNATURE ON FILE

14. DATE OF CURRENT 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD ILLNESS (First symptom) OR
YY GIVE FIRST DATE MM DD YY MM DD YY MM DD YY
INJURY (Accident) OR
08 20 XX
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM DD YY MM DD YY
17b. NPI FROM TO
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
YES X NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. 244 . 9 3. 733 . 00
23. PRIOR AUTHORIZATION NUMBER
2. 714 . 0 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

08 20 XX 08 20 XX 11 99214 123 85 00 1 NPI 0810998051

2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
66 6000600 X X YES NO $ 85 00 $20 00 $ 65 00
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #
INCLUDING DEGREES OR CREDENTIALS (970) 5553344
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.
FRONT RANGE FAMILY CARE FRONT RANGE FAMILY CARE
1800 CIRCLE COURT 1800 CIRCLE COURT
YOURTOWN CO 80000 YOURTOWN CO 80000
a. 0881099885 b. a. 0881099885 b.
SIGNED DATE

0205502LB03A-AK-13 AK-33
Medical Coding and Billing Specialist

Practice Exercise 27-3

1. 741.93
Coding pathway: Spina bifida 741.9 
Fifth-digit subclassification 3 = lumbar region
Tabular List description: 741.93 Spina bifida, Without mention of hydrocephalus,
lumbar region

2. 743.11
Coding pathway: Hypoplasia, eye (see also Microphthalmos)
New pathway: Microphthalmos, simple 743.11
Tabular List description: 743.11 Congenital anomalies of eye, Microphthalmos,
Simple microphthalmos

3. 744.01
Coding pathway: Absence, auditory canal (congenital) 744.01
Tabular List description: 744.01 Congenital anomalies of ear, face and neck,
Anomalies of ear causing impairment of hearing, Absence of external ear

4. 745.4
Coding pathway: Disease, Roger’s 745.4
Tabular List description: 745.4 Bulbus cordis anomalies and anomalies of
cardiac septal closure, Ventricular septal defect

5. 746.09
Coding pathway: Fallot’s, triad or trilogy 746.09
Tabular List description: 746.09 Other congenital anomalies of heart, Anomalies
of pulmonary valve, Other

6. 747.5
Coding pathway: Single, umbilical artery 747.5
Tabular List description: 747.5 Other congenital anomalies of circulatory
system, Absence or hypoplasia of umbilical artery

7. 748.4
Coding pathway: Honeycomb lung, congenital 748.4
Tabular List description: 748.4 Congenital anomalies of respiratory system,
Congenital cystic lung

AK-34 0205502LB03A-AK-13
 Pack 3—Answer Key

8. 749.22
Coding pathway: Cheilopalatoschisis—see also Cleft, palate, with cleft lip
New pathway: Cleft, palate, with cleft lip, unilateral, incomplete 749.22
Tabular List description: 749.22 Cleft palate and cleft lip, Cleft palate with cleft
lip, Unilateral, incomplete

9. 752.2 Didelphic uterus

Coding pathway: Didelphys, didelphic—see also Double uterus 752.2
Tabular List description: 752.2 Congenital anomalies of genital organs,
Doubling of uterus

10. 744.3 756.10 755.29 755.20 746.9

Coding pathway: Dysplasia – see also Anomaly
New pathway: Anomaly, auricle, ear 744.3
Tabular List description: 744.3 Congenital anomalies of ear, face and neck,
Unspecified anomaly of ear
Coding pathway: Anomaly, vertebra 756.10
Tabular List description: 756.10 Other congenital musculoskeletal anomalies,
Anomaly of spine, unspecified
Coding pathway: Hypoplasia, finger (see also Absence, finger, congenital)
New pathway: Absence, finger, congenital 755.29
Tabular List description: 755.29 Other congenital anomalies of limbs,
Longitudinal deficiency, phalanges, complete or partial
Coding pathway: Short, arm, congenital 755.20
Tabular List description: 755.20 Other congenital anomalies of limbs,
Unspecified reduction deformity of upper limb
Coding pathway: Disease, heart, congenital 746.9
Tabular List description: 746.9 Other congenital anomalies of heart, Unspecified
anomaly of heart

0205502LB03A-AK-13 AK-35
Medical Coding and Billing Specialist

Practice Exercise 27-4

1. V30.01 768.3 765.28

Coding pathway: Newborn, single, born in hospital, with cesarean delivery or
section V30.01
Tabular List description: V30.01 Single liveborn, Born in hospital, delivered by
cesarean delivery
Coding pathway: Distress, fetal, liveborn infant, first noted, during labor or
delivery 768.3
Tabular List description: 768.3 Intrauterine hypoxia and birth asphyxia, Fetal
distress first noted during labor, in liveborn infant
Coding pathway: Newborn, gestation, 35-36 completed weeks 765.28
Tabular List description: 765.28 Disorders relating to short gestation and low
birthweight, Weeks of gestation, 35-36 completed weeks of gestation

2. V30.00 766.1
Coding pathway: Newborn, single, born in hospital (without mention of cesarean
delivery or section) V30.00
Tabular List description: V30.00 Single liveborn, Born in hospital, delivered
without mention of cesarean delivery
Coding pathway: Large, for dates, fetus or newborn 766.1
Tabular List description: 766.1 Disorders relating to long gestation and high
birthweight, Other “heavy-for-dates” infants

3. V30.00 766.21 758.0

Coding pathway: Newborn, single, born in hospital (without mention of cesarean
delivery or section) V30.00
Tabular List description: V30.00 Single liveborn, Born in hospital, delivered
without mention of cesarean delivery
Coding pathway: Post-term, infant 766.21
Tabular List description: 766.21 Disorders relating to long gestation and high
birthweight, Late infant, not “heavy-for dates,” Post-term infant
Coding Pathway: Syndrome, Down’s 758.0
Tabular List description: 758.0 Chromosomal anomalies, Down’s syndrome

AK-36 0205502LB03A-AK-13
 Pack 3—Answer Key

4. V30.00 764.00 760.71

Coding pathway: Newborn, single, born in hospital (without mention of cesarean
delivery or section) V30.00
Tabular List description: V30.00 Single liveborn, Born in hospital, delivered
without mention of cesarean delivery
Coding pathway: Small, for dates, fetus or newborn 764.0 
Fifth-digit subclassification 0 = unspecified [weight]
Tabular List description: 764.00 Slow fetal growth and fetal malnutrition,
“Light-for-dates” without mention of fetal malnutrition, unspecified [weight]
Coding pathway: Syndrome, fetal alcohol 760.71
Tabular List description: 760.71 Fetus or newborn affected by maternal
conditions which may be unrelated to present pregnancy, Noxious influences
affecting fetus or newborn via placenta or breast milk, Alcohol

5. V32.01 765.26
Coding pathway: Newborn, twin, mate stillborn, born in hospital V32.0 
Fifth-digit subclassification 1 = delivered by cesarean delivery
Tabular List description: V32.01 Twin, mate stillborn, Born in hospital,
delivered by cesarean delivery
Coding pathway: Newborn, gestation, 31-32 completed weeks 765.26
Tabular List description: 765.26 Disorders relating to short gestation and low
birthweight, Weeks of gestation, 31 – 32 completed weeks of gestation

0205502LB03A-AK-13 AK-37
Medical Coding and Billing Specialist

Lesson 28
Practice Exercise 28-1

1. 780.03
Coding pathway: State, vegetative (persistent) 780.03
Alternative pathway: Vegetation, Vegetative, state (persistent) 780.03
Tabular List description: 780.03 Alteration of consciousness, Persistent vegetative state

2. 780.53
Coding pathway: Hypersomnia, unspecified, with sleep apnea, unspecified 780.53
Tabular List description: 780.53 General symptoms, Sleep disturbance,
Hypersomnia with sleep apnea, unspecified

3. 780.60
Coding pathway: Pyrexia (of unknown origin) 780.60
Tabular List description: 780.60 Fever, unspecified

4. 780.79
Coding pathway: Lethargy 780.79
Tabular List description: 780.79 Malaise and fatigue, Other malaise and fatigue

5. 781.4
Coding pathway: Monoplegia, transient 781.4
Tabular List description: 781.4 Transient paralysis of limb

6. 782.0
Coding pathway: Numbness 782.0
Tabular List description: 782.0 Disturbance of skin sensation

7. 786.59
Coding pathway: Discomfort, chest 786.59
Tabular List description: 786.59 Chest pain, Other

8. 796.2
Coding pathway: Elevation, blood pressure, reading, no diagnosis of hypertension 796.2
Tabular List description: 796.2 Elevated blood pressure reading without diagnosis
of hypertension

9. 795.00
Coding pathway: Abnormal, Papanicolaou (smear) cervix 795.00
Tabular List description: 795.00 Abnormal glandular Papanicolaou smear of cervix

AK-38 0205502LB03A-AK-13
 Pack 3—Answer Key

10. Coding pathway: Pain, pleuritic 786.52

Coding pathway: Fever, postoperative 780.62
1500 BLUE CROSS OF IOWA
PO BOX 1677
HEALTH INSURANCE CLAIM FORM
SIOUX CITY, IA 51102
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) X (SSN or ID) (SSN) (ID) 321001010
2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
TUCKER SALLY 11 26 1960 M F X SAME
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
1801 PETERSON COURT Self X Spouse Child Other

CITY STATE 8. PATIENT STATUS CITY STATE

SPRINGTOWN CO Single Married X Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
80002 (970) 5553255 Employed X Student Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER
TUCKER GREGORY BA1503
a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX
MM DD YY

402004679 LA4832 YES X NO M F

b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State)
b. EMPLOYER’S NAME OR SCHOOL NAME
MM DD YY

09 02 1961 M X F YES X NO ALLIED PROFESSIONS

c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
LAKESIDE AUTO YES X NO BLUE CROSS OF IOWA
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
MUTUAL LIFE X YES NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED SIGNATURE ON FILE DATE 06 06 XX SIGNED SIGNATURE ON FILE

14. DATE OF CURRENT 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD ILLNESS (First symptom) OR
YY GIVE FIRST DATE MM DD YY MM DD YY MM DD YY
INJURY (Accident) OR
06 06 XX
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
17a.
MM DD YY MM DD YY
17b. NPI FROM TO
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
YES X NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. 786 . 52 3. .
23. PRIOR AUTHORIZATION NUMBER
2. 780 . 62 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS OR EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

06 06 XX 06 06 XX 11 99214 12 85 00 1 NPI 0199654321

2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
99 9009009 X X YES 10 00 $
NO $ 75 00 85 00 $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #
INCLUDING DEGREES OR CREDENTIALS (970) 5551010
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.
STEWART CENTER FOR WOMEN STEWART CENTER FOR WOMEN
1200 CAROL LANE 1200 CAROL LANE
SIGNED DATE
YOURTOWN CO 80000 YOURTOWN CO 80000
a. 0220332233 b. a. 0220332233 b.

0205502LB03A-AK-13 AK-39
Medical Coding and Billing Specialist

Practice Exercise 28-2

1. 802.6
Coding pathway: Fracture, orbit, floor (blow-out) 802.6
Tabular List description: 802.6 Fracture of face bones, Orbital floor
(blow-out), closed

2. 806.01
Coding pathway: Fracture, vertebra, cervical, with spinal cord injury – see
Fracture, vertebra, with spinal cord injury, cervical
New pathway: Fracture, vertebra, with spinal cord injury, cervical 806.0 
Tabular List description: 806.01 Fracture of vertebral column with spinal cord
injury, Cervical, closed, C1-C4 level with complete lesion of cord

3. 812.52
Coding pathway: Fracture, humerus, condyle(s), lateral, open 812.52
Tabular List description: 812.52 Fracture of humerus, Lower end, open,
Lateral condyle

4. 839.20
Coding pathway: Displacement, intervertebral disc, due to trauma – see
Dislocation, vertebra, lumbar
New pathway: Dislocation, vertebra, lumbar 839.20
Tabular List description: 839.20 Other, multiple and ill-defined dislocations,
Thoracic and lumbar vertebra, closed, Lumbar vertebra

5. 845.13
Coding pathway: Rupture, joint capsule- see Sprain, by site
New pathway: Sprain, interphalangeal, toe 845.13
Tabular List description: 845.13 Sprains and strains of ankle and foot, Foot,
Interphalangeal (joint), toe

6. 852.15
Coding pathway: Hemorrhage, intracranial, traumatic – see Hemorrhage, brain,
traumatic, subarachnoid
New pathway: Hemorrhage, brain, traumatic, subarachnoid, with open
intracranial wound 852.1 
Fifth-digit subclassification 5 = with prolonged [more than 24 hours] loss of
consciousness, without return to pre-existing conscious level
Tabular List description: 852.15 Subarachnoid hemorrhage following injury
with open intracranial wound, with prolonged [more than 24 hours] loss of
consciousness, without return to pre-existing conscious level

AK-40 0205502LB03A-AK-13
 Pack 3—Answer Key

7. 810.03 831.01
Coding pathway: Fracture, clavicle, acromial end 810.03
Tabular List description: 810.03 Fracture of clavicle, Closed, acromial end
of clavicle
Coding pathway: Dislocation, humerus, proximal end, anterior 831.01
Tabular List: 831.01 Dislocation of shoulder, Closed dislocation, anterior
dislocation of humerus

8. 812.00 820.8
Coding pathway: Fracture, humerus, proximal end – see Fracture, humerus,
upper end; Fracture, humerus, upper end 812.00
Tabular List description: 812.00 Fracture of humerus, Upper end, closed,
Upper end, unspecified part
Coding pathway: Fracture, femur, neck 820.8
Tabular List description: 820.8 Fracture of neck of femur, Unspecified part
of neck of femur, closed

Practice Exercise 28-3

1. 871.3 873.42
Coding pathway: Enucleation of eye 871.3
Tabular List: 871.3 Open wound of eyeball, Avulsion of eye
Coding pathway: Laceration – see also Wound, open, by site
New pathway: Wound, open, forehead 873.42
Tabular List: 873.42 Other open wound of head, Face, without mention of
complication, Forehead

2. 881.20
Coding pathway: Laceration – see also Wound, open, by site
New pathway: Wound, open, forearm, with tendon involvement 881.20
Tabular List: 881.20 Open wound of elbow, forearm and wrist, With tendon
involvement, forearm

0205502LB03A-AK-13 AK-41
Medical Coding and Billing Specialist

3. 821.11 904.2
Coding pathway: Fracture, femur, shaft, open 821.11
Tabular List: 821.11 Fracture of other and unspecified parts of femur, Shaft or
unspecified part, open, Shaft
Coding pathway: Avulsion, blood vessel – see Injury, blood vessel, by site
New pathway: Injury, blood vessel, femoral, vein 904.2
Tabular List: 904.2 Injury to blood vessel of lower extremity and unspecified
sites, Femoral veins

4. 917.2
Coding pathway: Blister – see also Injury, superficial, by site
New pathway: Injury, superficial, heel (and foot or toe) 917 
Fourth-digit 2 = Blister without mention of infection
Tabular List: 917.2 Superficial injury of foot and toe(s), Blister without mention
of infection

5. 802.0 921.0 920

Coding pathway: Fracture, nose 802.0
Tabular List: 802.0 Fracture of face bones, Nasal bones, closed
Coding pathway: Black, eye 921.0
Tabular List: 921.0 Black eye, not otherwise specified
Coding pathway: Contusion, face 920
Tabular List: 920 Contusion of face, scalp and neck except eye(s)

6. 824.1 928.21
Coding pathway: Fracture, malleolus, medial, open 824.1
Tabular List: 824.1 Fracture of ankle, Medial malleolus, open
Coding pathway: Crush, ankle 928.21
Tabular List: 928.21 Crushing injury of lower limb, Ankle and foot, excluding
toe(s) alone, Ankle

AK-42 0205502LB03A-AK-13
 Pack 3—Answer Key

7. 945.26 942.24 948.10

Coding pathway: Burn, thigh, second degree 945.26
Tabular List: 945.26 Burns of lower limb(s), Blisters, epidermal loss [second
degree], thigh [any part]
Coding pathway: Burn, back, second degree 942.24
Tabular List: 942.24 Burn of trunk, Blisters, epidermal loss [second degree],
back [any part]
Coding pathway: Burn, extent (percent of body surface), 10-19 percent 948.1 
Fifth-digit 0 = less than 10 percent or unspecified as third degree
Tabular List: 948.10 Burns classified according to extent of body surface
involved, 10-19 percent of body surface

8. 967.0 E851
Table of Drugs and Chemicals: Barbiturates, barbituric acid
Poisoning: 967.0 Accident: E851
Tabular List: 967.0 Poisoning by sedatives and hypnotics, Barbiturates
Tabular List: E851 Accidental poisoning by barbiturates

9. 982.8 E950.9
Table of Drugs and Chemicals: Nail polish remover
Poisoning: 982.8 Suicide Attempt: E950.9
Tabular List: 982.8 Toxic effect of solvents other than petroleum-based, Other
nonpetroleum-based solvents
Tabular List: E950.9 Suicide and self-inflicted poisoning by solid or liquid
substances, Other and unspecified solid and liquid substances

0205502LB03A-AK-13 AK-43
Medical Coding and Billing Specialist

10. Coding pathway: Burn, forearm, second degree 943.21

Coding pathway: Burn, extent, less than 10 percent 948.00
Fifth-digit 0= less than 10 percent or unspecified (third degree burn)

1500 MOUNTAIN STATES

1801 SW VINE STREET
HEALTH INSURANCE CLAIM FORM
DENVER, CO 80217
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
CHAMPUS HEALTH PLAN BLK LUNG
(Medicare #) (Medicaid#) (Sponsor’s SSN) (Member ID #) X (SSN or ID) (SSN) (ID) 012345678
2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
GIBBS STEVEN 08 10 2000 M X F GIBBS MICHAEL
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)
1343 OVAL STREET Self Spouse Child X Other SAME
CITY STATE 8.PATIENT STATUS CITY STATE
WINDSOR CO Single X Married Other

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
Full-Time Part-Time
80520 (970) 5557643 Employed
Student X Student
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER
NONE 420
a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES X NO 02 11 1969 M X F
b. OTHER INSURED’S DATE OF BIRTH SEX b. AUTO ACCIDENT? Place (State) b. EMPLOYER’S NAME OR SCHOOL NAME
M F YES X NO ADVANCED COMMUNICATIONS
c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES X NO MOUNTAIN STATES
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES X NO If yes, return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary I authorize payment of medical benefits to the undersigned physician or
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. supplier for services described below.

SIGNED SIGNATURE ON FILE DATE 09 10 XX SIGNED SIGNATURE ON FILE

14. DATE OF CURRENT ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
INJURY (Accident) OR GIVE FIRST DATE
09 10 XX
PREGNANCY (LMP) FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

17b. NPI FROM TO

19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES
YES X NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3, or 4 to Item 24E by Line.) 22. MEDICAID RESUBMISSION
CODE ORIGINAL REF. NO.
1. 943 . 21 3. .
23. PRIOR AUTHORIZATION NUMBER
2. 948 . 00 4. .
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
FROM TO PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS FAMILY QUAL. PROVIDER ID. #
1.

09 10 XX 09 10 XX 11 99204 12 88 00 1 NPI
2.

NPI
3.

NPI
4.

NPI
5.

NPI
6.

NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
987 21 5432 X X YES NO $ 88 00 $ 0 00 $ 88 00
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING 33. BILLING PROVIDER INFO & PH #
DEGREES OR CREDENTIALS (I certify that the statements on the 32. SERVICE FACILITY LOCATION INFORMATION (970) 5551717
reverse apply to this bill and are made a part thereof.)
ERIC SULLIMAN MD ERIC SULLIMAN MD
1000 MAIN STREET 1000 MAIN STREET
YOURTOWN CO 80000 YOURTOWN CO 80000
SIGNED DATE a. 0377484809 b. a. 0377484809 b.

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 Pack 3—Answer Key

Lesson 29
Practice Exercise 29-1

1. 198.3 V10.3
Coding pathway: Carcinoma – see also Neoplasm, by site, malignant
New pathway: Neoplasm, brain, malignant, secondary 198.3
Tabular List: 198.3 Secondary malignant neoplasm of other unspecified sites,
Brain and spinal cord
Coding pathway: History (personal) (of), malignant neoplasm (of), breast V10.3
Tabular List: V10.3 Personal history of malignant neoplasm, Breast

2. 786.50 V45.89
Coding pathway: Pain, chest 786.50
Tabular List: 786.50 Chest pain, unspecified
Coding pathway: Status, postsurgical V45.89
Tabular List: V45.89 Other postprocedural status, Other

3. 650 V27.0
Coding pathway: Delivery, normal –see category 650
Tabular List: 650 Normal delivery
Coding pathway: Outcome of delivery, single, liveborn V27.0
Tabular List: V27.0 Outcome of delivery, Single liveborn

4. V72.31
Coding pathway: Examination, gynecological V72.31
Tabular List: V72.31 Special investigations and examinations, Gynecological
examination, Routine gynecological examination

0205502LB03A-AK-13 AK-45
Medical Coding and Billing Specialist

Practice Exercise 29-2

1. 842.00 E849.4 E885.2

Coding pathway: Sprain, wrist 842.00
Tabular List: 842.00 Sprains and strains of wrist and hand, Wrist, Unspecified site
Index to External Causes: Accident, occurring (at), park (public) E849.4
Tabular List: E849.4 Place of occurrence, Place for recreation and sport
Index to External Causes: Fall, from, skateboard E885.2
Tabular List: E885.2 Fall on same level from slipping, tripping, or stumbling,
Fall from skateboard

2. 945.30 948.33 E803.1

Coding pathway: Burns, leg, third degree 945.30
Tabular List: 945.30 Burn of lower limb(s), Full-thickness skin loss [third
degree NOS], lower limb [leg], unspecified site
Coding pathway: Burns, extent (percent of body surface), 30-39 percent 948.3  .
Remember, each anterior or posterior leg equals 9%. For our diagnosis, two
anterior legs equal 18% and two posterior legs equal 18%. This results in a total
of 36% body surface burned.
Fifth-digit subclassification 3 = 30-39 percent (third degree burn)
Tabular List: 948.33 Burns classified according to extent of body surface
involved, 30-39 percent of body surface
Index to External Causes: Explosion, railway engine, locomotive, train E803 
Fourth-digit 1 = Passenger on railway
Tabular List: E803.1 Railway accident involving explosion, fire, or burning,
Passenger on railway

3. 922.2 E812.1
Coding pathway: Contusions, abdomen 922.2
Tabular List: 922.2 Contusion of trunk, Abdominal wall
Index to External Causes: Collision, motor vehicle and another motor vehicle
E812 
Fourth-digit 1 = Passenger in motor vehicle other than motorcycle
Tabular List: E812.1 Other motor vehicle accident involving collision with
motor vehicle
Note: only “how” is coded because “where” is not documented.

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 Pack 3—Answer Key

4. 813.42 E849.0 E888.9

Coding pathway: Fracture, radius, distal end – see Fracture, radius, lower end
New pathway: Fracture, radius, lower end 813.42
Tabular List: 813.42 Fracture of radius and ulna, Lower end, closed, Other
fractures of distal end of radius (alone)
Index to External Causes: Accident, occurring (at), home E849.0
Tabular List: E849.0 Place of occurrence, Home
Index to External Causes: Fall, falling (accidental) E888.9
Tabular list: E888.9 Other and unspecified fall

Practice Exercise 29-3

998.59
Coding pathway: Infection, postoperative, wound 998.59
Tabular List: 998.59 Other complications of procedures, not elsewhere classified,
postoperative infection, Other postoperative infection

Practice Exercise 29-4

250.50 362.02 V58.67
Coding pathway: Diabetes, diabetic, retinopathy, proliferative 250.5 [362.02]
Tabular List: 250.50 Diabetes with ophthalmic manifestations
Fifth-digit 0 = type 2 or unspecified type, not stated as uncontrolled
Tabular List: 362.02 Diabetic retinopathy, Proliferative diabetic retinopathy
Coding pathway: Long-term, insulin V58.67
Tabular List: Long-term (current) use of insulin

Practice Exercise 29-5

486
Coding pathway: Pneumonia 486
Tabular List: 486 Pneumonia, organism unspecified

0205502LB03A-AK-13 AK-47
Medical Coding and Billing Specialist

Practice Exercise 29-6

720.9 722.10
Coding pathway: Spondylopathy, inflammatory 720.9
Tabular List: 720.9 Ankylosing spondylitis and other inflammatory spondylopathies,
Unspecified inflammatory spondylopathy
Coding pathway: Protrusion, intervertebral disc—see Displacement, intervertebral disc
New pathway: Displacement, intervertebral disc, lumbar 722.10
Tabular List: 722.10 Intervertebral disc disorders, Displacement of thoracic or lumbar
intervertebral disc without myelopathy, Lumbar intervertebral disc without myelopathy

Practice Exercise 29-7

714.0 718.97 733.19 733.00 V13.51
Coding pathway: Arthritis, rheumatoid 714.0
Tabular List: 714.0 Rheumatoid arthritis and other inflammatory polyarthropathies,
Rheumatoid arthritis
Coding pathway: Destruction, joint—see also Derangement, joint
New pathway: Derangement, joint, foot 718.97
Tabular List: 718.97 Other derangement of joint, Unspecified derangement of joint,
ankle and foot
Coding pathway: Fracture, pathologic, specified site 733.19
Tabular List: 733.19 Other disorders of bone and cartilage, Pathologic fracture,
Pathologic fracture of other specified site
Coding pathway: Osteoporosis (generalized) 733.00
Tabular List: 733.00 Other disorders of bone and cartilage, Osteoporosis,
Osteoporosis, unspecified
Coding pathway: History of, fracture, healed, pathological V13.51
Tabular List: Personal history of other diseases, Pathological fracture

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 Pack 3—Answer Key

Practice Exercise 29-8

250.60 357.2 438.9 V58.67
Coding pathway: Diabetes, neuropathy; type 2 250.6 [357.2]; type 2
Tabular List description: 250.60 Diabetes with neurological manifestations; type 2
Tabular List description: 357.2 Polyneuropathy in diabetes
Coding pathway: Late effects (of), cerebrovascular disease 438.9
Tabular List description: 438.9 Unspecified late effects of cerebrovascular disease
Coding pathway: Long-term, insulin V58.67
Tabular List description: V58.67 Long-term (current) use of insulin

Practice Exercise 29-9

813.41
Coding pathway: Fracture, Colles’ 813.41
Tabular List: 813.41 Fracture of radius and ulna, lower end, closed, Colles’ fracture

Practice Exercise 29-10

288.60
Coding pathway: Leukocytosis 288.60
Tabular List: 288.60 Diseases of white blood cells, Leukocytosis, unspecified

Practice Exercise 29-11

455.1
Coding pathway: Hemorrhoids, internal, thrombosed 455.1
Tabular List: 455.1 Hemorrhoids, Internal thrombosed hemorrhoids

0205502LB03A-AK-13 AK-49
Medical Coding and Billing Specialist

Practice Exercise 29-12

836.0 836.1
Coding pathway: Tear, meniscus, medial 836.0
Tabular List: 836.0 Dislocation of knee, Tear of medical cartilage or meniscus of
knee, current
Coding pathway: Tear, meniscus, lateral 836.1
Tabular List: 836.1 Dislocation of knee, Tear of lateral cartilage or
meniscus of knee, current

Lesson 30
Practice Exercise 30-1

1. Electronic health records will replace paper health records.

2. People will use personal health records and take more responsibility for
their health and well-being

3. Providers will move toward an electronic document management system

based on computers.

4. Electronic coding will complete many of the easy, simple coding tasks.

5. More and more coders will telecommute from home.

AK-50 0205502LB03A-AK-13