Medical Coder Topics :-

Anatomy Basics:-
1. Skeletal System:

 Function: Provides structure and support, protects internal organs, facilitates movement, stores
minerals (e.g., calcium), and produces blood cells.
 Major Bones: Skull, spine (vertebrae), rib cage, pelvis, limbs (humerus, radius, ulna, femur, tibia,
fibula), and smaller bones (patella, carpals, tarsals).

2. Muscular System:

 Function: Facilitates movement, maintains posture, and produces heat.

 Types of Muscles: Skeletal (voluntary movement), smooth (involuntary movement, found in organs),
and cardiac (heart muscle).

3. Circulatory System:

 Function: Transports oxygen, nutrients, hormones, and waste products throughout the body.
 Major Components: Heart, blood vessels (arteries, veins, capillaries), and blood.

4. Respiratory System:

 Function: Facilitates gas exchange (oxygen and carbon dioxide) between the body and the
environment.
 Major Components: Nose, pharynx, larynx, trachea, bronchi, lungs, and diaphragm.

5. Digestive System:

 Function: Breaks down food into nutrients, absorbs nutrients, and eliminates waste.
 Major Components: Mouth, esophagus, stomach, small intestine, large intestine, liver, pancreas,
gallbladder.

6. Nervous System:

 Function: Controls and coordinates body activities, processes sensory information, and facilitates
communication between different parts of the body.
 Major Components: Brain, spinal cord, peripheral nerves.

7. Endocrine System:

 Function: Produces and secretes hormones that regulate various body functions (metabolism, growth,
development, reproduction).
 Major Components: Hypothalamus, pituitary gland, thyroid gland, adrenal glands, pancreas, ovaries
(in females), and testes (in males).

8. Lymphatic System:

 Function: Maintains fluid balance, absorbs fats from the digestive system, and provides immune
defense.
 Major Components: Lymph nodes, lymphatic vessels, spleen, thymus, tonsils.
9. Urinary System:

 Function: Removes waste products from the blood, regulates fluid and electrolyte balance, and
maintains acid-base balance.
 Major Components: Kidneys, ureters, bladder, urethra.

10. Reproductive System:

 Function: Produces gametes (sperm in males, eggs in females), facilitates fertilization, supports the
development of offspring.
 Major Components:
o Male: Testes, vas deferens, seminal vesicles, prostate gland, penis.
o Female: Ovaries, fallopian tubes, uterus, vagina.

11. Integumentary System:

 Function: Protects the body, regulates temperature, provides sensory information.

 Major Components: Skin, hair, nails, sweat glands, sebaceous (oil) glands.

Key Terms:

 Cell: The basic structural and functional unit of all living organisms.
 Tissue: A group of similar cells that perform a specific function. Major types include epithelial,
connective, muscle, and nervous tissues.
 Organ: A structure composed of different types of tissues working together to perform specific
functions.
 System: A group of organs that work together to perform complex body functions.

Interview Topics:-
Role of Cerebellum: The cerebellum is responsible for coordinating voluntary movements, maintaining
posture, balance, and fine-tuning motor activities. It ensures smooth and balanced muscular activity.

Rib Cage Function: The rib cage protects vital organs such as the heart and lungs, supports the upper body, and
assists in the breathing process by expanding and contracting.

Diaphragm Functions: The diaphragm is the primary muscle used in the process of breathing. It contracts to
create a vacuum that pulls air into the lungs and relaxes to expel air from the lungs.

Digestive and Endocrine Systems:

 Digestive System: Breaks down food into nutrients, absorbs nutrients into the bloodstream, and
eliminates waste.
 Endocrine System: Produces hormones that regulate metabolism, growth, development, tissue
function, sexual function, reproduction, sleep, and mood.

Epithelial Tissues: Epithelial tissues line the cavities and surfaces of blood vessels and organs throughout the
body. They protect, secrete, absorb, excrete, and sense stimuli.

Patella: The patella, or kneecap, protects the knee joint and improves the leverage of the thigh muscles, making
leg movements more efficient.
Respiratory System: The respiratory system facilitates the exchange of gases (oxygen and carbon dioxide)
between the body and the environment. It includes organs such as the nose, trachea, lungs, and diaphragm.

Reproductive System: The reproductive system is responsible for producing gametes (sperm in males and eggs
in females), facilitating fertilization, and supporting the development of offspring.

Lymphatic System: The lymphatic system helps maintain fluid balance, absorbs fats from the digestive system,
and contributes to the body's immune defense by producing and transporting lymph, a fluid containing infection-
fighting white blood cells.

Nervous System: The nervous system controls and coordinates body activities by transmitting signals between
different parts of the body. It consists of the central nervous system (brain and spinal cord) and the peripheral
nervous system.

Functions of Cerebrum, Cerebellum, Medulla, Arteries:

 Cerebrum: Responsible for higher brain functions, including thought, action, reasoning, and sensory
processing.
 Cerebellum: Coordinates voluntary movements, posture, and balance.
 Medulla: Controls autonomic functions like breathing, heart rate, and blood pressure.
 Arteries: Carry oxygen-rich blood away from the heart to the tissues of the body.

Primary Treatment for Sepsis: Immediate treatment typically involves intravenous antibiotics and fluids. In
severe cases, vasopressors, oxygen, and other supportive therapies may be needed.

Medical Term for Stones in Gall Bladder: Cholelithiasis.

CABG: Coronary Artery Bypass Grafting, a surgical procedure used to treat coronary artery disease by
improving blood flow to the heart.

DEXA: Dual-Energy X-ray Absorptiometry, a scan used to measure bone density.

Osteoporosis and Osteopenia:

 Osteoporosis: A condition where bones become weak and brittle due to a decrease in bone density.
 Osteopenia: A condition characterized by lower than average bone density, but not low enough to be
classified as osteoporosis.

Adrenal Glands: The adrenal glands produce hormones such as cortisol, adrenaline, and aldosterone, which
help regulate metabolism, immune response, blood pressure, and stress response.

Questions

1. What is the functional unit of the kidney? Nephron.

2. Where are red blood cells produced? In the bone marrow.
3. Which part of the brain is responsible for coordination and balance? The cerebellum.
4. Which bone is known as the Collarbone? Clavicle.
5. Which is the largest artery in the human body? The aorta.
6. What type of joint is found in the shoulder? Ball-and-socket joint.
7. What is the primary function of hemoglobin in the blood? To carry oxygen from the lungs to the
body's tissues and return carbon dioxide from the tissues back to the lungs.
8. Which organ is primarily responsible for detoxification of the blood? The liver.
9. Which part of the cell is responsible for producing energy? Mitochondria.
10. Which muscle is responsible for the movement of the forearm? The biceps brachii (flexion) and
triceps brachii (extension).
11. What is the smallest bone in the human body? The stapes in the ear.
12. What type of tissue connects bones at a joint? Ligaments.
 13. What is the primary function of white blood cells? To fight infection and protect the body against
foreign invaders.
14. What is the largest muscle in the human body? The gluteus maximus.
15. Which structure connects muscles to bones? Tendons.
16. Where are red blood cells produced? In the bone marrow.
17. What is the main function of the large intestine? To absorb water and electrolytes from indigestible
food matter and to form and expel feces.
18. Which part of the heart pumps oxygenated blood to the body? The left ventricle.

Additional Questions

What does Remission Mean? A period during which the symptoms of a disease are reduced or disappear.

What is Osteomalacia? A condition characterized by the softening of bones due to defective bone
mineralization, often caused by vitamin D deficiency.

What is the primary purpose of Z codes in ICD-10? Z codes are used to identify reasons for encounters other
than a disease or injury, such as a person with a health condition that influences their care or to indicate the
status or history of a disease.

Is diabetes mellitus and diabetes insipidus the same? No, they are different conditions. Diabetes mellitus is
related to blood sugar regulation, whereas diabetes insipidus is related to the kidneys' ability to retain water.

What is the defined time period for sequela in ICD-10 coding guidelines? There is no defined time period;
sequela can be coded any time after the initial injury or illness if the residual condition is directly related.

What is the difference between an ulcer and a pressure ulcer? An ulcer is a general term for a sore on the
skin or a mucous membrane, while a pressure ulcer (or bedsore) specifically results from prolonged pressure on
the skin.

Which organ is responsible for detoxification? The liver.

What does ICD-10 stand for? International Classification of Diseases, 10th Revision.

Can congenital and acquired codes of the same condition be coded at the same time in ICD-10? No,
generally only one code should be used, and the coder should choose the most appropriate code to reflect the
patient's condition.

What is the purpose of a modifier in CPT? Modifiers provide additional information about the performed
procedure without changing the procedure's definition. They can indicate that a service or procedure has been
altered in some specific way.

What is the defined postpartum period according to ICD-10 guidelines? The postpartum period is defined
as the first six weeks (42 days) after delivery.

Which hormone is secreted by the ovaries? Estrogen and progesterone.

ICD and CPT Coding Guidelines:-
ICD (International Classification of Diseases)

ICD-10-CM (Clinical Modification):

 Purpose: Used for diagnosis coding in all healthcare settings.

 Structure: Alphanumeric codes (e.g., A00.0 to Z99.9) representing specific diagnoses.
 Guidelines:
o Primary Diagnosis: The main reason for the patient's visit or admission.
o Secondary Diagnoses: Additional conditions that coexist at the time of the visit and affect
patient care.
o Laterality: Codes specify the side of the body affected (e.g., right, left, bilateral).
o Combination Codes: Single codes that classify two diagnoses or a diagnosis with an
associated secondary process.
o Sequela (Late Effects): Residual effects after the acute phase of an illness or injury has
ended; there is no defined time period for sequela in ICD-10.
o Inclusion and Exclusion Notes: Help identify when certain conditions should or should not
be coded together.
o Z Codes: Used for factors influencing health status and contact with health services (e.g.,
family history, screenings, routine exams).
o Postpartum Period: Defined as the first six weeks (42 days) after delivery.

ICD-10-PCS (Procedure Coding System):

 Purpose: Used for inpatient hospital procedure coding.

 Structure: Seven-character alphanumeric codes, each character representing a specific aspect of the
procedure (e.g., body system, root operation, approach).

CPT (Current Procedural Terminology)

CPT Codes:

 Purpose: Used for reporting medical, surgical, and diagnostic procedures and services performed by
healthcare providers.
 Structure: Five-digit numeric codes (e.g., 99213 for an office visit).
 Categories:
o Category I: Codes for widely performed procedures and services.
o Category II: Optional tracking codes for performance measurement.
o Category III: Temporary codes for emerging technologies, services, and procedures.

Modifiers:

 Purpose: Provide additional information about the performed procedure without changing its
definition.
 Structure: Two-character codes (e.g., -25 for a significant, separately identifiable evaluation and
management service on the same day as another service).
 Guidelines:
o Use Modifiers Appropriately: To indicate that a service or procedure has been altered in a
specific way (e.g., more extensive, bilateral procedure).
o Global Periods: Understand the global surgical package, which includes preoperative,
intraoperative, and postoperative care.

Evaluation and Management (E/M) Coding:

 Purpose: Codes for patient encounters (e.g., office visits, hospital visits).
  Components:
o History: Chief complaint, history of present illness, review of systems, past medical, family,
and social history.
o Examination: Level of examination performed.
o Medical Decision Making: Complexity of establishing a diagnosis and/or selecting a
management option.
 2021 Guidelines for Office/Outpatient E/M Services:
o Based on Medical Decision Making or Total Time: Simplified documentation by focusing
on the complexity of medical decision making or the total time spent on the day of the
encounter.

Common Guidelines for Both ICD and CPT:

 Accurate Documentation: Ensure thorough and precise documentation in the medical record to
support the codes reported.
 Code to the Highest Specificity: Use the most specific code available to describe the patient's
condition and the services provided.
 Avoid Unbundling: Do not separately code procedures that are part of a comprehensive service.
 Stay Current: Regularly update coding knowledge to stay compliant with changes in coding
guidelines and practices.

ICD Coding Conventions:-

ICD (International Classification of Diseases) coding conventions are a set of general rules that guide the
selection of the correct diagnosis codes. Understanding these conventions ensures accurate and consistent
coding across various healthcare settings. Below are the key ICD-10-CM coding conventions:

1. Format and Structure:

 Code Structure: ICD-10-CM codes are alphanumeric and consist of up to seven characters. Each
character has a specific meaning:
o The first character is always a letter.
o The second character is always numeric.
o The remaining characters can be either letters or numbers.
o Codes are structured in a hierarchical format (e.g., C00-C96 for neoplasms).

2. Alphabetic Index and Tabular List:

 Alphabetic Index: A list of diseases and conditions in alphabetical order. It includes main terms,
subterms, and instructional notes.
 Tabular List: A structured list of codes divided into chapters based on body systems or conditions.

3. Conventions:

 Abbreviations:
o NEC (Not Elsewhere Classified): Used when a specific code is not available for a condition.
o NOS (Not Otherwise Specified): Used when the documentation does not provide enough
detail to assign a more specific code.
 Punctuation:
o [ ] (Square Brackets): Enclose synonyms, alternative wordings, or explanatory phrases.
o ( ) (Parentheses): Enclose supplementary words that may be present or absent in the
statement of a disease without affecting the code number.
o : (Colon): Used in the Tabular List after an incomplete term that needs one or more of the
following modifiers to make it assignable to a given category.
  Instructional Notes:
o Includes: Further defines or provides examples of the content of a category.
o Excludes1: Indicates that the code excluded should never be used at the same time as the code
above the Excludes1 note.
o Excludes2: Indicates that the condition excluded is not part of the condition represented by
the code, but a patient may have both conditions at the same time.
o Code First: Indicates that the underlying condition must be sequenced before the
manifestation code.
o Use Additional Code: Indicates that an additional code should be used to provide a more
complete picture of the diagnosis.
o Code Also: Instructs that two codes may be needed to fully describe a condition, and this note
does not provide sequencing direction.

4. Combination Codes:

 A single code used to classify two diagnoses, or a diagnosis with an associated secondary process
(manifestation) or a diagnosis with an associated complication.

5. Laterality:

 Codes that specify the side of the body affected by the condition (e.g., right, left, bilateral).

6. Sequela (Late Effects):

 Residual effects after the acute phase of an illness or injury has ended. There is no time limit on when a
sequela code can be used.

7. Symptoms, Signs, and Abnormal Findings:

 Codes for symptoms, signs, and abnormal findings should not be used when a related definitive
diagnosis has been established. If no diagnosis is established, they can be used.

8. Principal Diagnosis:

 The condition established after study to be chiefly responsible for occasioning the admission of the
patient to the hospital for care.

9. Secondary Diagnoses:

 Conditions that coexist at the time of admission, develop subsequently, or affect the treatment received
and/or the length of stay.

10. Z Codes:

 Used to represent reasons for encounters when a patient is not currently sick, such as routine checkups,
vaccinations, screenings, and personal or family history of disease.

11. Chapter-Specific Guidelines:

 Each chapter of ICD-10-CM has specific guidelines that must be followed in addition to the general
coding conventions.
12. Placeholder 'X':

 Used in certain codes to allow for future expansion and to fill out empty characters when a code has
fewer than six characters and a seventh character is required.

Practical Examples

1. Abdominal Pain, NOS:

o Alphabetic Index: Look up "Pain" and find "Abdominal" which might lead to "R10.9."
o Tabular List: Verify "R10.9" (Unspecified abdominal pain) and ensure it accurately describes
the condition.

2. Diabetes with Kidney Complications:

o Alphabetic Index: Look up "Diabetes" and find "with kidney complications."
o Tabular List: Verify the specific code (e.g., "E11.22" for Type 2 diabetes mellitus with
diabetic chronic kidney disease) and use additional codes if needed to specify the stage of
chronic kidney disease.

Technical Questions:-
1. Can you explain the difference between EHR and EMR?
o "An Electronic Medical Record (EMR) is a digital version of a patient's chart within a single healthcare
provider's practice. It includes the patient's medical and treatment history. An Electronic Health Record
(EHR) is more comprehensive and can be shared across different healthcare settings, providing a broader
view of a patient's health history."
2. What are the benefits of using EHR systems for healthcare providers?
o "EHR systems improve the accuracy and clarity of medical records, enhance coordination of care among
providers, increase efficiency by reducing paperwork, and improve patient safety through features like
drug interaction alerts. They also facilitate better data analysis and reporting."
3. Can you describe some of the key features of an EHR system?
o "Key features of an EHR system include patient demographics, medical history, medication lists,
immunization records, laboratory test results, clinical notes, billing information, and decision support
tools. EHR systems also provide functionalities for scheduling, e-prescribing, and secure messaging."
4. What do you understand by the term 'interoperability' in healthcare IT?
o "Interoperability refers to the ability of different EHR systems and healthcare applications to exchange,
interpret, and use data cohesively. It ensures that patient information is accessible and usable across
different healthcare settings, which is crucial for coordinated and efficient patient care."
5. How do EHR systems improve patient care and safety?
o "EHR systems improve patient care and safety by providing accurate and up-to-date patient information,
reducing medical errors through alerts and reminders, enabling better coordination among healthcare
providers, and facilitating evidence-based decision-making."