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Chapter 12 Medical Insurance Coding 231
with malignant neoplasms, you need to know if it is primary, secondary, or in situ. This information will come
from the physician. If the determination of benign or
malignant has not been made, you will need the physician to specify whether it is a neoplasm with uncertain
behavior or unspecied behavior.
Table of Drugs and Chemicals
This table contains a long list of medicines, drugs, and
other substances. It shows the code to assign when a
patient is harmed by a drug, or other substance, in each
of these circumstances:
Accidental poisoning—The patient received an acci-
r
dental overdose of the drug or was given or took the
drug by mistake.
Therapeutic use—The patient took or received the
r
drug in the right dose to treat or prevent a disease.
Suicide attempt—The patient took the drug in an
r
effort to poison or injure himself.
Assault—Someone gave the patient the drug in a
r
deliberate attempt to harm him.
Undetermined—It’s not known whether the poisoning
r
or injury from the drug was intended or accidental.
The Main Term Rule
The rst step in coding a diagnosis is to locate the
main term in the diagnosis statement. This will usually
appear on the progress notes in the patient’s medical
chart. The diagnosis usually will be listed there as the
impression. The main term rule means that you look for
the main term in the diagnosis or description. As you
are coding, you need to look for the key words within
the diagnosis.
Applying the Main Term Rule
For example, the main term for the diagnosis of malignant hypertension is hypertension, because it represents
the actual condition. Hypertension is the term you look
up in the alphabetic index. Under hypertension, you nd
all the different types of hypertension listed. Malignant
will be one of the types.
Exceptions to the Main Term Rule
Keep these exceptions to the main term rule in mind
when you use the alphabetic index:
1. Obstetric conditions may be found under these main
terms:
Delivery
r
Pregnancy
r
Puerperal
r
2. Complications of medical or surgical procedures are
listed under complication.
3. Z codes are found under main entries such as:
Admissions
r
Examination
r
History of observation
r
Problem (with)
r
Status
r
Vaccination
r
Encounter for
r
Study Skill
Proper coding takes time and practice, a lot of practice. Utilize every opportunity you have to explore
the codes with the ICD-10-CM, CPT, and HCPCS.
Look up diagnoses and procedures that interest you.
Think through the process of patient care and then
code accordingly. Use the tips throughout this chapter to help you become comfortable and efcient in
your coding.
Primary Codes
A patient will have a primary diagnosis on each visit
to the ofce. This is simply the patient’s chief complaint
or the reason he sought medical attention that day. The
code for that diagnosis, complaint, or reason is the primary code for the visit. The primary diagnosis code is
always listed rst. In some cases, the primary diagnosis may not be the only reason for the visit. In cases of
comorbidity, more than one disease or condition occur-
ring at the same time, the reason for the patient’s visit
is complicated by a secondary diagnosis or diagnoses.
These codes need to be listed to give an accurate picture
of the patient’s overall health. For example, a patient who
has insulin-dependent diabetes mellitus comes in for the
u. Since the interaction between her diabetes and the u
will affect treatment and prognosis, list both diagnoses.
Since her diabetes can complicate the treatment and progression of the u, list it as a secondary code.
Therefore, you would code the diagnosis of type I
diabetes mellitus below the primary code of the u.
Late Effects
Late effects are conditions that result from a past injury
or illness. They are present long after treatment for the
injury or illness has ended. For example, patients who
have suffered a stroke, known as a cerebrovascular accident (CVA) in the past, may have effects that linger after
their recovery.
For instance, a patient may have a diagnosis of left
hemiparesis (paralysis) resulting from a stroke 3 years
earlier. For this patient’s visit, you would code the current
condition, left hemiparesis, rst, as the primary diagnosis.
The code number identifying the cause, the stroke,
which is the original illness or injury, comes second.
232 Section III Administrative Medical Assistant Skills
Table 12-3
Seventh character to be added to each S23 code
A Initial encounter
D Subsequent encounter
S Sequela
Example of Late Effects Coding
S23.10 Subluxation and dislocation of unspecied
S23.100 Subluxation of T1/T2 thoracic vertebra
S23.101 Dislocation of T1/T2 thoracic vertebra
Note:
For an initial encounter with a diagnosis of subluxation and
dislocation of unspecied thoracic vertebra = S23.10XA
X is used as a placeholder for digits that are not used.
A diagnosis of Initial Subluxation of T1/T2 thoracic
vertebra = S23.100A
Late Effects Codes
thoracic vertebra
Table 12-3 is an example of the page showing the late
effects codes that are always coded rst, followed by the
code identifying the cause. An example of this type of
coding is also shown in the table.
Coding Suspected Conditions
In hospitals, medical coders don’t list patients’ diagnoses
until testing is complete. In other words, they code from
complete information. In a medical ofce, you have to
report the reason for the patient’s visit when it occurs.
You’ll be limited by the information available at the
time. Often, this will be only the patient’s complaint and
the physician’s best guess about what is causing it. The
physician may write probable or rule out along with
his suspected diagnosis. However, you cannot code this
diagnosis as the reason for the visit until it’s conrmed.
You don’t want to put in the patient’s record that he has
a condition he may not really have. Instead, you should
code the reason the patient came in. That reason could
be a test result that was abnormal, a sign or a symptom.
Here’s an example: A patient makes an appointment
because he’s been having severe headaches. The physician suspects a brain tumor and schedules the patient for
an MRI (magnetic resonance imaging) of his head. The
physician writes rule out brain tumor in the patient’s
chart. But you can’t code the diagnosis as brain tumor
until the MRI test conrms it. You don’t have that information on this visit. Therefore, you will code the symptom of severe headaches.
C
O
G
The CPT-4 is the fourth edition of Current Procedural
Terminology. The book lists codes for common medi-
cal procedures and services. It was rst published by
CPT-4 CODING MANUAL
the American Medical Association (AMA) in 1966. The
fourth edition was published in 1977. That was the last
major revision of the book but it is updated every year.
A CPT code is a ve-digit numeric code for a specic
medical procedure or service that a physician provides to
a patient. The main code for a procedure is listed rst
followed by other codes that offer additional services or
details that are indented below it. CPT codes can also
have modiers, which offer additional special information. You’ll read more about modiers later in this chapter.
Patient Education
When a physician orders certain tests or proce-
dures, they may require preauthorization the insur-
ance company. Sometimes, this can be difcult
to explain to the patient. It is important that the
patient understands that even though the physi-
cian ordered the test or procedure we must follow
the insurance companies guidelines. Be sure they
understand that failure to obtain a preauthoriza-
tion can result in the insurance company not pay-
ing for the test or procedure. MRI is one example
of a test that must be preauthorized. The patient
is responsible to pay for the cost of the test if the
insurance company does not cover it.
CPT Coding
The CPT codes are divided into six sections. The codes
in each section of the CPT-4 are listed by number and
are organized by the type of service. The six sections of
the CPT-4 are:
Evaluation and management—These are the codes
r
used to charge for ofce visits. All codes in this section begin with the number 9.
Anesthesia—These codes are organized according to
r
body site (head, thorax, hip, etc.). Then, under each
body site, the specic procedure code is listed. These
codes all begin with 0.
Surgery—Surgery codes begin with numbers 1
r
through 6. Like the anesthesia codes, they are organized according to which part of the body is involved.
Radiology—All radiology codes begin with the
r
number 7.
Pathology and laboratory—This section includes
r
every lab test that can be ordered. These codes all
begin with 8.
Medicine—These codes cover nonsurgical treatments
r
and services that ordinarily take place in a doctor’s
ofce such as injections and global surgical follow-up,
an inclusive package of all the procedures and visits surrounding a surgical procedure. They all begin with a 9,
just like the evaluation and management (E/M) codes.
Chapter 12 Medical Insurance Coding 233
Appendix N—Summary of resequenced CPT codes
Table 12-4
99201—New Patient Visit:
Problem-focused history and exam
Straightforward decision making
Face-to-face time 10 minutes
99202—New Patient Visit
Expand Problem-focused
Low complexity decision making
Face to face time 20 minutes
Examples of E/M Codes
r
(re sequencing # symbol)
Appendix O—multianalyte assays with algorithmic
r
analyses
Symbols in the CPT-4
There are symbols used in the CPT coding book that
require special attention. These symbols are listed at the
bottom of each page and many of them correlate to a
particular Appendix. Here are some of the symbols you
will need to become familiar with:
Table 12-4 provides examples of E/M codes found in
the CPT book.
Section Guidelines
Each section begins with a set of guidelines for coding
the kinds of procedures listed in that particular section.
Pay close attention to these guidelines as they contain
useful information, such as:
Denitions and explanations to assist the coder
r
A list of procedures new to the section
r
Modiers that can be used with the section’s codes
r
Codes to use when an unlisted procedure is performed
r
Directions on how to le a special report
r
Appendices
There are several appendices listed in the book of the
CPT book immediately following the coding sections.
The appendix you will use most frequently is Appendix
A as it provides a complete listing of all modiers.
Additionally, Appendix C can be helpful if you are having difculty determining an E/M code. Below is a guide
to the appendices:
Appendix A—all modiers that are used to alter or
r
Appendix B—complete list of additions to/deletions
r
from and revisions of CPT manual
Appendix C—clinical examples of many of the evalu-
r
ation and management codes (E/M)
Appendix D—lists all add-on codes (+)
r
Appendix F—summary of CPT codes modier −63
r
exempt −63 identies procedures that are performed
on infants <4 kg or 8.8 pounds and represents a signicant increase in physician’s work and complexity
of service/procedure; may be reviewed for increase in
reimbursement
Appendix G—summary of moderate (conscious)
r
sedation codes (bull’s-eye)
Appendix L—vascular families
r
Appendix M—Summary of cross-walked deleted
r
CPT codes, lists current-year code to replace a deleted
code.
● New code (Appendix B)
▲ Revised code-changed denition or terms (Appendix B)
; Separates “base denition” from “indented” code
denitions
►◄ New or revised text
+ Add-on codes (Appendix D)
|
Modier “–51” exempt (Appendix E)
# Resequenced codes (Appendix N)
○ Recycled or reinstated code
The Index
The nal part of the CPT-4 is an index that lists every
procedure alphabetically. You use this index similar to
the way you use the alphabetic index in the ICD-10-CM.
That is, you look up the procedure in the CPT index rst
and then nd the number it gives in the lists of codes.
Never use codes from the index without crossreferencing them. Additional information about each code
is found in the numeric section. Sometimes, this additional
information will change the initial code you selected.
HCPCS
The Healthcare Common Procedure Coding System
(HCPCS) lists codes not included in the CPT. HCPCS
codes are used for services and supplies provided to
patients and covered by Medicare and Medicaid (as
well as other insurances). These services include the
following:
Ambulance service
r
Wheelchairs
r
Orthotics (devices to assist a weakened limb)
r
Hearing and vision services
r
Medications (administered medications and chemo-
r
therapy drug, other than oral)
Bandaging supplies
r
Durable medical equipment
r
Outpatient surgery centers must use these codes
when reporting charges for any patient who receives
health benets sponsored by the federal government.
This requirement also applies to hospitals that perform
outpatient surgery.
234 Section III Administrative Medical Assistant Skills
There are two levels of HCPCS codes:
Level 1 codes are included in the CPT-4 lists. They are
r
used with level 2 codes to provide greater detail about
services and supplies.
Level 2 codes are ve-digit codes that begin with
r
the letter A to V, followed by a four-digit number.
For example, L8100 is the code for an elastic support stocking, ending below the knee and of medium
weight.
C
O
G
It’s helpful to know the basics about each type of codes,
even if you never work in that kind of ofce. Here are
some tips and examples for using each type.
CODING SERVICES
ANDPROCEDURES
Evaluation and Management Codes
The evaluation and management (E/M) codes are used
to charge for the patient’s visit with the physician. That
visit can take place in any number of places. Here are
just some of the possible settings for a patient visit.
Ofce
r
Hospital room
r
Hospital emergency room
r
Patient’s home
r
Nursing home
r
Rehabilitation facility
r
Basically, each E/M code measures the physician’s
level of involvement with the patient. This can range
from a short visit that deals with a single, simple problem to a longer visit in which the physician deals with
several problems that are difcult or severe.
The rst three factors are
physical examination, and medical decision making.
The rest are contributing factors in determining the level
of the visit.
All three key components must be present to assign an
E/M code to a new patient visit. For current or “established” patients, two key components are required.
Case Question
A
F
F
nizations. Her visit is coded as an E/M service.
Do you think we should code this as a routine
ofce visit or a physical examination visit? It’s
important to recognize when a patient is being
seen for an annual well visit. Such visits must be
coded as a physical examination with the proper
CPT and ICD codes. Many insurance plans allow
one annual physical per year payable at 100%.
Remember from our case study that
Jessica McNeil came to the ofce for
a prekindergarten physical and immu-
key components—history,
Coding Consultations
There are four categories of consultations that include
ofce, initial inpatient, follow-up inpatient, and conrmatory. Each category has its own reporting instructions. When a physician asks another provider for advice
about a specic problem, the second provider becomes a
consultant. The initial encounter is coded as a consultation. The documentation must support this.
A letter must accompany the patient seeing the
r
consultant.
The consultant must send a letter back to the rst
r
physician outlining the ndings.
Selecting an E/M Code
It’s always the physician’s job to decide which E/M
code to assign to a visit. However, you should know
what each requires that supports the assigning of that
code. That way, you can be sure the chart information supports the code and the billing will be correct.
There may be times when you will have to discuss
code assignments with the physician to insure the code
assigned.
All E/M codes are based on these seven factors:
1. History
2. Physical examination
3. Medical decision making
4. Nature of the presenting problem
5. Counseling the patient or a family member
6. Time—the length of the visit
7. Coordination of care with other providers
If the consultant takes over part or all of the patient’s
care, follow-ups are coded as regular visits. A conrmatory consultation is considered a second opinion.
The consultant offers only an opinion and advice.
r
A conrmatory consultant does not take over treat-
r
ment of the patient.
Anesthesia and Surgery Codes
The anesthesia codes and the surgery codes are closely
related in these ways:
Both are organized by the place on the body being
r
treated.
Both are then subdivided by the procedure being per-
r
formed on that part of the body.
Both are coded by medical ofce staff even if the pro-
r
cedure takes place in a hospital.
Chapter 12 Medical Insurance Coding 235
The anesthesia section of the CPT-4 uses two types
of modiers. These are letters, or numbers, added to a
code to provide more detail. One anesthesia modier
is a standard type found in all sections of the CPT. The
other type is a special
two-digit code that begins with the letter P and ends
in a number from 1 to 6. The physical status modier tells the patient’s condition, at the time of anesthesia administration. It helps determine the difculty of
the service the anesthesiologist performed. For example, a P1 modier shows the anesthesia was given to
a normal, healthy patient. A P5 modier indicates a
patient who was not expected to survive without the
procedure.
physical status modier. It is a
Surgical Procedures
Many surgical procedures are coded as a surgical package. Included in the package CPT code are as follows:
After the surgery has been decided, there can be
r
one related E/M meeting immediately before or on
the day of the surgery to gather history and other
information.
Administration of local anesthesia.
r
The operation itself.
r
Normal follow-up care after the operation.
r
These different components are bundled together and
included in a single code. As long as the surgery goes
as planned, there is no need for additional codes. Any
procedures to deal with these complications are coded
separately.
Each surgical code has a set number of follow-up
days for care after surgery. Be sure that you know these
limits are so that you can bill for any extra hospital,
ofce, or other outpatient visits. Also, the surgical package only includes follow-up care directly related to the
recovery from the procedure itself; not related conditions or complications.
Coding Inpatient Services
That’s why you may be coding services that take place
outside your medical ofce.
Other Surgical Coding Tips
Here are some other things you should know about
using the surgical codes in the CPT-4:
The integumentary system—This section of surgical
r
codes has codes for which a measurement is needed.
The size of the defect and the size of the specimen
both must be measured before they are sent to the
lab for testing. All codes listed in this section include
simple closure.
Repairs—The CPT-4 denes three types of repairs—
r
simple, intermediate, and complex. Repairs should
be measured in centimeters so they can be coded
properly.
Cast reapplication—You can’t assign the same code
r
to replacing a cast as you did to the original cast
application. That’s because the original code includes
treatment of the fracture; replacing the cast does not.
Therefore, the replacement code carries a lower payment rate.
Multiple procedures on the same day—Code these
r
procedures separately unless they are part of a
package. They are coded in order, from major
procedures to minor ones with the appropriate
modier(s).
Modiers offer additional information that are added
to a code. Table 12-5 shows a few of the more commonly used modiers.
Radiology Codes
The radiology section of the CPT-4 is divided into four
parts to match the four main types of radiology services:
Diagnostic radiology (diagnostic imaging)
r
Diagnostic ultrasound
r
Radiation oncology (radiation therapy)
r
Nuclear medicine
r
Most of the coding in a medical ofce is for outpatients; however, you may do inpatient coding too. This
is because hospitals only bill for services they provide.
For example, if a patient is hospitalized for surgery,
the hospital will bill for the patient’s room and meals,
nursing care, the use of the operating room and recovery room, and so on. That bill does not include the
surgeon or anesthesiologist services. Medical ofce
coders are concerned only with the physician’s services, no matter where they are performed. So if a physician from your ofce examines or treats a patient in
the hospital, you’ll code these services and submit the
charges for them. Basically, billing is determined by
who provides the service, not by where it’s performed.
Table 12-5
25 Signicant, Separately Identiable Evaluation and
Management Service by the Same Physician on the
Same Day of the Procedure or Other Service
27 Multiple Outpatient Hospital E/M Encounters on the
Same Date
22 Increased Procedural Services
50 Bilateral Procedure
51 Multiple Procedures
52 Reduced Services
Common Modiers
236 Section III Administrative Medical Assistant Skills
Within each part, the codes generally are arranged
by anatomic site—from the top of the body to the bottom. Many codes indicate the number of views in a
particular test. That’s because the more views there are,
the greater the costs for lm, developing, and the technician’s time.
Some radiology tests require the use of a contrast
medium, a liquid administered to the patient to enhance
the image on the lm. The codes for these tests indicate
either with contrast or without contrast. Here is how to
assign the correct code:
If the contrast medium is given intravascularly
r
(injected into the bloodstream), code the test with
contrast.
If the contrast medium is given orally or rectally, use
r
the test code for without contrast.
If the same physician performs, supervises, and interprets the procedure, two codes are used. For example,
the physician may inject the contrast medium, supervise the test, and interpret the results. The code for
the procedure is found in the surgery, radiology, or
medicine section. The code for supervision and interpretation is found in the radiology section. The physician must put a written report in the patient’s medical
record in order to bill this second code. If two physicians are involved in the procedure, for example, a surgeon and a radiologist, the radiology portion is billed
by the radiologist.
Pathology and Laboratory Codes
These codes are divided into several sections that include
the following:
Drug testing
r
Panels of tests
r
Chemistry testing
r
Antibody testing
r
Urinalysis
r
Consultations with pathologists
r
The pathology and laboratory section contains codes
for just about every blood test and combination of tests
a physician might order. The last part of the section
includes services and procedures provided by a pathologist. These include the following:
Gross (can be seen by the naked eye) examination of
r
tissue removed during surgery
Examination by microscope of tissue removed during
r
surgery
Postmortem examination or autopsy
r
Each tissue specimen is submitted under a different identifying code for diagnosis by the pathologist.
The codes represent the level of the physician’s work.
TheCPT-4 also provides codes for reporting postmortem exams and autopsies.
Coding Automated Multichannel Tests
Some laboratory tests are ordered and performed
in panels. This means a series of tests are performed
together resulting in cost-savings. For this purpose, the
codes from all the tests performed are bundled into one
main code. It is important to remember that these panel
codes cannot be
bill separately for the tests. They must be billed together
under one code. For example, a Basic Metabolic Panel
80047 contains the following tests:
Calcium, ionized (82330)
r
Carbon dioxide (82374)
r
Chloride (82435)
r
Creatinine (82565)
r
Glucose (82947)
r
Potassium (84132)
r
Sodium (84295)
r
Urea nitrogen (BUN) (84520)
r
unbundled, which means you cannot
Using the Medicine Codes
Like the other ve sections of the CPT-4 book, this section includes guidelines for proper coding. Pay special
attention to the information about coding immunizations. Immunization injections are usually given when
the patient comes to the ofce for a routine physical
exam, or for some minor problem. When an immunization injection is given at such times, use two codes, one
for the visit (E/M code) and the other for the injection.
Another important tip to remember is that when you are
coding for injections (other than immunizations), you
will need two codes, the CPT code for the procedure of
giving the injection along with a HCPCS code for the
actual medication. Although you have two codes, there
should only be one charge and should be listed with the
medication.
CPT Tips
Here are some nal tips for becoming a good medical
coder:
Always use the latest edition of the CPT code book.
r
Refer to guidelines in each section regularly. Don’t
r
expect to know all the guidelines from memory. It
can’t be done!
Make sure diagnosis codes clearly support CPT codes,
r
but never change an ICD code just to accomplish this.
Never hesitate to ask the physician to clarify a code,
r
procedure, or chart documentation.
Know the CPT modiers and use them when
r
appropriate.
Chapter 12 Medical Insurance Coding 237
Ethics
There are numerous cases in which physicians
have lost their practice, and their freedom, due to
Medicare and/or Medicaid fraud. Know what services were provided and code accordingly. If you
have questions, ask. Never submit claims for procedures or services that were not provided. Protect
your professional reputation. Always ask questions if you have any doubts before submitting a
claim. If you witness fraud, be sure to report it to
CMS, or OIG.
C
O
G
The CMS (Centers for Medicare and Medicaid Services)
and the OIG (Ofce of Inspector General) dene healthcare fraud as:
false claim is fraud, whether payment is made or not.
CODING AND FRAUD
To knowingly and willfully execute (or attempt
to execute) a scheme to defraud any health care
benet program or to obtain money/property
from a health care benet program through false
representations.
It’s important to note that the mere act of ling a
To combat fraud, CMS hires outside organizations to
randomly review Medicare claims and compare them
to the medical records of those patients. Many private
insurance companies and state insurance departments
also have units to combat fraud.
In medical coding, the most common examples of
fraud are upcoding and unbundling.
Upcoding is submitting a code for a service the physi-
r
cian hasn’t performed. This often involves coding a
service related to but more complex (and thus more
expensive) than what was actually provided.
Unbundling is submitting a code for each piece of
r
a service package, instead of the single code for the
entire package. Its goal is to gain greater payment by
charging for each service separately.
Medicare has the same authority as the Internal
Revenue Service (IRS) to audit your ofce’s nancial
records. This means the claims you code and submit
could be audited months or years after payment has
been received. Remember if you nd that you have
made in error on any claim, it is vitally important that
you inform the physician and/or ofce manager. Then
notify the insurance company and make any necessary
corrections.
The bottom line on fraud is don’t do it! Not only is
it illegal and the penalties severe, but submitting a false
claim is a violation of your professional ethics as a medical assistant.
Procedure 12-1 Coding a Diagnosis or Diagnoses
Purpose: To accurately code the diagnosis or diagnoses
for medical services and procedures provided to insure
proper reimbursement from third-party payers.
Equipment: Patient records of diagnosis/diagnoses and
treatment, current ICD coding book.
Step 1: Using the primary diagnosis, locate the main
term (or cause) within the diagnosis. For example, if the
diagnosis is CHF (congestive heart failure), the main
term is failure.
Step 2: Locate the main term in the alphabetic section
of the ICD coding book. Following our example, locate
“failure.”
Step 3: Refer to the additional descriptive terms or
information within the diagnosis. For CHF, our next
identier would be “heart” as it describes the location
of the failure. Notice “heart” is indented under the main
term “failure.” Continue searching until all terms within
the diagnosis have been located.
Step 4: Follow any special instructions given within
the coding book. For example, “see also ….” If the section ever states “see condition,” you will need to revisit
your diagnosis and select a different main term. It does
not mean go to the section “condition.”
Step 5: Cross-reference the selected code with the
numeric section of the ICD coding book. Read through
the descriptive of the code selected. Look for any additional digit requirements to insure your code fully
describes the diagnosis.
Step 6: Assign the code.
238 Section III Administrative Medical Assistant Skills
Procedure 12-2 Assigning a Procedural Code
Purpose: To determine and assign the most accurate
code for services and procedures performed by the provider to insure full and proper reimbursement.
Equipment: Patient records of services and procedures
performed, current CPT coding book.
Step 1: Identify the exact service or procedure
performed.
Step 2: Using the index in the book of the CPT book,
locate the procedure. Utilize the code or code range to crossreference to the front of the book. *Important note: Even
if only one code is listed for a particular service, it must be
cross-referenced to insure that it is the correct code.*
Step 3: Locate the code or code range and read through
the primary procedure(s) listed. Select the primary procedure that describes the service or procedure performed.
Preparing for Externship
It is critical that a medical assistant know and understand their scope of practice. You are not allowed to
practice medicine. So what does that mean? It means
that you cannot diagnose a patient’s problem nor
can you make medical suggestions to a patient. For
example, a patient may ask your opinion about something the physician has prescribed or recommended.
Step 4: Read through the indented description below
the code you selected. Locate the code that matches the
procedure in as much detail as possible.
Step 5: Be sure to read through the “Special
Guidelines” section located at the front of the coding
section to insure that all guidelines are followed.
Step 6: Determine if a modier is needed. Remember, any
unusual or special circumstance will require a modier. A
modier allows for additional information to be provided.
Step 7: If a modier is need, or if you are uncertain,
review the modier summaries on the front cover to
locate possible modiers. Then, cross-reference selected
modiers to the Modier Appendix. Review the details
of each modier to select the correct one.
Step 8: Assign the selected code with modier(s), if
required.
If you offer even an opinion, it can be interpreted as
practicing medicine. So on your externship or when
you are on the job, how do you deal with this type
of situation? Always refer the patient’s concerns or
questions back to the physician. Support the physician’s treatment plan for the patient. You can have an
opinion but keep those opinions to yourself.
Chapter Recap
● Diagnostic coding involves using alphanumeric
characters to describe diseases, injuries, and other
reasons for seeking medical care.
● Diagnostic coding is linked to reimbursement because
it assures that the services and procedures provided
by physicians are medically necessary.
● ICD-10-CM is used for diagnostic coding.
● Procedural coding involves using numbers to describe
procedures and other services physicians provide to
patients.
● Complete and accurate coding is necessary to ensure
proper reimbursement.
● The CPT-4 is used for procedural coding. It is
organized by the type of service provided.
● Using the CPT-4 is similar to using the ICD-9-CM
because the index in each book is consulted rst.
● To ensure accuracy in diagnostic and procedural
coding, the most recent version of each book must
be used.
Modiers are used to provide additional information about a procedure.
There can be up to seven characters in an ICD-10
code
HCPCS is used to code procedures and services
not in the CPT book such as medications.
Z codes are used when a patient is not currently ill
but is seeking medical care, such as annual physicals and pregnancy.
Chapter 12 Medical Insurance Coding 239
Online Resources for Students
Resources for students available on thepoint.
lww.com include the following:
● Audio Glossary
● Animations
Exercises and Activities
Certication Preparation Questions
1. When coding the patient’s diagnosis you
woulduse:
a. CPT-4.
b. HCPCS.
c. ICD-10-CM.
d. ICD-10-PCS.
e. CPT-4-CM.
2. E/M codes can be found in:
a. CPT-4.
b. HCPCS.
c. ICD-10-CM.
d. ICD-10-HCP.
e. CPT-4-CM.
3. Two-digit codes used to give additional
information regarding procedures are referred
toas:
a. upcoding.
b. modiers.
c. downcoding.
d. bundling.
e. unbundling.
4. ICD-10 codes can contain up to (maximum):
a. ve characters.
b. four characters.
c. six characters.
d. three characters.
e. seven characters.
5. Codes used when a patient is not currently ill but
seeks medical advice are:
a. V codes.
b. Z codes.
c. W codes.
d. Y codes.
e. U codes.
● Competency Evaluation Forms
● Harris CareTracker Case Studies
● Interactive Games & Activities
● Certication Preparation Question Bank
● Videos
6. Submitting a code for services the physician did
not perform or greater than those performed is
called:
a. downcoding.
b. bundling.
c. upcoding.
d. unbundling.
e. upbundling.
7. When a code contains more than one test it is
called:
a. downcoding.
b. bundling.
c. upcoding.
d. unbundling.
e. upbundling.
8. Sally is seen in the ofce for evaluation of a
sprained ankle. Which coding book would you use
to code her ofce visit?
a. CPT-4
b. HCPCS
c. ICD-10-CM
d. ICD-10-PCS
e. CPT-4-CM
9. Sally had to have her ankle wrapped with a
3″ elastic bandage. Which book would you use
to code for the bandage?
a. CPT-4
b. HCPCS
c. ICD-10-CM
d. ICD-10-PCS
e. CPT-4-CM
240 Section III Administrative Medical Assistant Skills
10. After reviewing x-rays, the doctor diagnosed Sally
with a third-degree sprain of her right ankle.
Which book would you use to code her diagnosis?
a. CPT-4
b. HCPCS
c. ICD-10-CM
d. ICD-10-PCS
e. CPT-4-CM
P
S
Y
Access these Web sites for additional information on
insurance coding and insurance fraud:
Center for Medicare and Medicaid Services: www.
Ofce of Inspector General: www.oig.hhs.gov
Internet Resources
cms.gov