BILLING AND C ODING REFERENCE M ANUAL

S ECTION 1: H EALTHCARE REIMBURSEMENT BASICS

OVERVIEW OF THE U.S. H EALTHCARE P AYMENT SYSTEMS

The U.S. healthcare system is a complex mix of public and private payers that reimburse
providers for delivering medical services. Understanding how these systems operate is
essential for accurate billing and coding.

1. P UBLIC P AYMENT SYSTEMS

A. Medicare

 Administered by: Centers for Medicare & Medicaid Services (CMS)

 Eligibility: Primarily individuals aged 65+, people with certain disabilities, and those
with end-stage renal disease (ESRD)
 Coverage Types:
o Part A: Inpatient hospital care
o Part B: Outpatient services and physician visits
o Part C (Medicare Advantage): Managed care offered through private
insurers
o Part D: Prescription drugs

B. Medicaid

 Jointly funded by: Federal and state governments

 Administered by: Each state
 Eligibility: Low-income individuals and families, pregnant women, children, disabled
individuals
 Variability: Coverage and reimbursement vary by state

C. Other Public Programs

 TRICARE: Military personnel and families

 Veterans’ Health Administration (VA): Veterans
 Indian Health Service (IHS): American Indians and Alaska Natives
 CHIP: Children in families with incomes too high for Medicaid but too low to afford
private coverage

2. P RIVATE P AYMENT SYSTEMS

A. Employer-Sponsored Insurance (ESI)

 Most common form of insurance in the U.S.

  Employers share premium costs with employees
 Often managed through third-party administrators or private insurance companies

B. Individual/Marketplace Insurance

 Purchased via the Health Insurance Marketplace under the Affordable Care Act (ACA)
 Offers standardized coverage levels (Bronze, Silver, Gold, Platinum)
 Subsidies available for low-income individuals

3. P AYMENT M ODELS

A. Fee-for-Service (FFS)

 Providers are paid for each service rendered

 Encourages volume over value

B. Value-Based Payment Models

 Emphasize quality and cost-efficiency

 Examples:
o Pay-for-Performance (P4P)
o Bundled Payments
o Accountable Care Organizations (acos)
o Patient-Centered Medical Homes (PCMH)

C. Capitation

 Providers receive a fixed amount per patient per period, regardless of services
provided
 Common in HMO’S and certain Medicaid managed care models

4. R EIMBURSEMENT M ECHANISMS

 Inpatient Prospective Payment System (IPPS): Uses MS-DRGS for hospital stays
 Outpatient Prospective Payment System (OPPS): Uses APCS
 Resource-Based Relative Value Scale (RBRVS): Determines physician payment
under Medicare Part B
 Ambulatory Surgical Center (ASC) Payment System
 Skilled Nursing Facility (SNF), Home Health, and Hospice Reimbursement
Systems

K EY ROLES IN HEALTHCARE REIMBURSEMENT :

1. Setting Payment Policies and Fee Schedules

CMS develops and maintains:

  Medicare Physician Fee Schedule (MPFS)
 Outpatient Prospective Payment System (OPPS)
 Inpatient Prospective Payment System (IPPS)
 Ambulatory Payment Classifications (APCS)
 Medicare Severity-Diagnosis Related Groups (MS-DRGS)

These determine how providers are paid for services rendered to Medicare beneficiaries.

2. Implementing Value-Based Care Initiatives

CMS ties reimbursement to quality and efficiency through programs like:

 Hospital Value-Based Purchasing (HVBP) Program

 Merit-based Incentive Payment System (MIPS)
 Accountable Care Organizations (ACOS)
These programs reward or penalize providers based on performance metrics.

💰 HOW HEALTHCARE P ROVIDERS GET P AID (R EIMBURSEMENT M ECHANISMS )

When doctors, hospitals, or clinics provide care to patients (especially those on Medicare), they
get paid in different ways depending on the type of service. Here are some of the main ways:

Inpatient Prospective Payment System (IPPS)

o Used when a patient stays overnight in the hospital.

o Payment is based on MS-DRGs – groups that classify the patient’s condition
and how sick they are.
o Example: If two people have pneumonia but one is more severely ill, the
hospital gets more money for the sicker patient.

Outpatient Prospective Payment System (OPPS)

o Used for services like ER visits, x-rays, or same-day surgeries.

o Payments are based on APCs (Ambulatory Payment Classifications),
which group similar outpatient services.

RBRVS (Resource-Based Relative Value Scale)

o Used to figure out how much a doctor should be paid for a visit or procedure.
o It considers: the time, skill, and cost of providing the service.
o Used under Medicare Part B (which covers outpatient and doctor services).

Ambulatory Surgical Center (ASC) Payment System

o Pays for surgeries done in special facilities (not full hospitals) where patients
go home the same day.

SNF, Home Health, and Hospice Payment Systems

o Different payment systems are used for:

 Skilled Nursing Facilities (SNFs) (like rehab centers after hospital
stays),
  Home health services (nurses or therapists who come to your
home),
 Hospice care (end-of-life care).

🏥 WHO SETS THE P AYMENT RULES ? (K EY ROLES)

The government agency CMS (Centers for Medicare & Medicaid Services) is in charge of:

 Creating rules for how much to pay doctors and hospitals.

 Maintaining different fee schedules like:
o MPFS (Medicare Physician Fee Schedule) for doctors.
o OPPS and IPPS for hospitals.
o APCs and MS-DRGs to group services and conditions.

These rules tell providers how much Medicare will pay for each type of care.

🎯 P AYING FOR Q UALITY , N OT J UST Q UANTITY (VALUE -BASED C ARE )

Instead of just paying for every visit or test, Medicare wants to reward providers who
give better care. This is called value-based care.

They use special programs to do this:

Hospital Value-Based Purchasing (HVBP)

o Hospitals get more or less money based on how well they care for patients
(like preventing infections or keeping readmission rates low).

Merit-based Incentive Payment System (MIPS)

o Doctors are scored on how well they care for patients. High scores = more
money, low scores = penalties.

Accountable Care Organizations (ACOs)

o Groups of doctors and hospitals that work together to keep patients healthy
and reduce unnecessary care.
o If they save Medicare money and keep patients healthy, they share in the
savings.

K EY ACRONYMS & D EFINITIONS IN MEDICAL C ODING AND BILLING

Government Agencies & Programs

 CMS – Centers for Medicare & Medicaid Services: Oversees Medicare, Medicaid, CHIP,
and ACA Marketplace.
  HIPAA – Health Insurance Portability and Accountability Act: Sets standards for
privacy, security, and electronic healthcare transactions.
 OIG – Office of Inspector General: Enforces laws against healthcare fraud and abuse.

Coding Systems

 ICD-10-CM – International Classification of Diseases, 10th Revision, Clinical

Modification: Used to code diagnoses and conditions.
 ICD-10-PCS – Procedure Coding System: Used for inpatient hospital procedure coding
(U.S. only).
 CPT® – Current Procedural Terminology: Codes for outpatient and physician
procedures/services (owned by AMA).
 HCPCS – Healthcare Common Procedure Coding System: Includes CPT® codes (Level
I) and national codes for supplies, equipment, etc. (Level II).
 DRG – Diagnosis-Related Group: Determines payment for inpatient hospital stays (MS-
drgs for Medicare).
 APC – Ambulatory Payment Classification: Outpatient facility payment grouping under
OPPS.

Insurance & Reimbursement

 EOB – Explanation of Benefits: Sent by payer to explain payment decisions.

 RA – Remittance Advice: Electronic version of EOB for providers.
 NPI – National Provider Identifier: A unique 10-digit number assigned to healthcare
providers.
 POS – Place of Service: 2-digit codes indicating where a service was provided.
 MAC – Medicare Administrative Contractor: Processes Medicare claims and issues lcds.

Billing & Documentation

 EMR/EHR – Electronic Medical Record/Electronic Health Record: Digital systems for

documenting patient encounters.
 ABN – Advance Beneficiary Notice of Noncoverage: Notifies Medicare patients of
services likely not covered.
 RVU – Relative Value Unit: Determines Medicare reimbursement based on work,
practice expense, and liability.

Quality & Value Programs

 MIPS – Merit-Based Incentive Payment System: CMS program that adjusts payment
based on quality reporting and performance.
 QPP – Quality Payment Program: Umbrella program for MIPS and Advanced apms.
 ACO – Accountable Care Organization: Groups of providers that coordinate care and
share in savings for quality performance.

Claim Processing

 CMS-1500 – Claim form for outpatient and professional services.

 UB-04 – Claim form for hospital/inpatient services.
 EDI – Electronic Data Interchange: Electronic transmission of billing data.
 TPA – Third Party Administrator: Processes insurance claims on behalf of another
company.

IMPORTANT MEDICAL C ODING GUIDELINES

Evaluation and Management (E/M)

  E/M coding is critical for documenting patient visits and procedures, typically following
the SOAP format.

Compliance with Medicare Regulations

 Knowledge of National Coverage Determinations (ncds) and Local Coverage

Determinations (lcds) is essential for coding correctly based on Medicare policies.

Advance Beneficiary Notices (abns)

 Abns inform patients about potential out-of-pocket costs for services that Medicare
may not cover, emphasizing coding accuracy related to medical necessity.

Key Compliance Documents

 OIG Compliance Program Guidance assists provider offices in creating compliance

manuals and staying informed about potential problem areas in claims submissions
through the OIG Work Plan.

The Minimum Necessary Rule

 Under HIPAA, this rule requires limiting access to protected health information to only
those individuals whose job necessitates it.

🔹 GENERAL MEDICAL C ODING T ERMS

Acronym Definition
ASC Ambulatory Surgery Center – Outpatient facility for surgical procedures.
Applied to Deductible – Amount applied to the patient's annual
ATD
deductible.
AOB Assignment of Benefits – Insurance pays the provider directly.
CARC Claim Adjustment Reason Code – Explains claim payment adjustments.
RARC Remittance Advice Remark Code – Additional details on claim adjustments.
CO/OA/PI/ Contractual Obligation / Other Adjustment / Payer Initiated / Patient
PR Responsibility – Claim adjustment group codes.
COB Coordination of Benefits – Determines primary and secondary payers.
CPT Current Procedural Terminology – Procedure codes by AMA.
DCI Duplicate Coverage Inquiry – Verifying if a patient has overlapping insurance.
DOS Date of Service – When the care was provided.
EDI Electronic Data Interchange – Digital communication of billing info.
EFT Electronic Funds Transfer – Digital transfer of payments.
EMR/EHR Electronic Medical/Health Records – Digital patient records.
EOB Explanation of Benefits – Summary of insurance claim decisions.
ERA Electronic Remittance Advice – Digital version of EOB.
FDCPA Fair Debt Collection Practices Act – Regulates medical debt collections.
FFS Fee-for-Service – Providers paid per service rendered.
FI Fiscal Intermediary – Processes Medicare claims.
Healthcare Common Procedure Coding System – Includes CPT and non-physician
HCPCS
items.
Health Insurance Portability & Accountability Act – Regulates health info
HIPAA
privacy and security.
ICD-10 International Classification of Diseases, 10th Rev. – Diagnostic coding system.
INN / OON In-Network / Out-of-Network – Participating vs. Non-participating providers.
MACRA Medicare Access and CHIP Reauthorization Act – Created MIPS and QPP.
Acronym Definition
N/C Non-Covered Charge – Not covered by the insurance plan.
Not Elsewhere Classifiable – ICD-10 term when a condition doesn’t fit other
NEC
codes.
NDC National Drug Code – Unique identifier for medications.
NPI National Provider Identifier – Unique ID for healthcare providers.
PA Prior Authorization – Insurer approval required before certain care.
PCP Primary Care Physician – Gatekeeper in managed care plans.
PHI Protected Health Information – Confidential patient data.
RBRVS Resource-Based Relative Value Scale – Sets Medicare payment amounts.
RVU Relative Value Unit – Measures resources used in a medical service.
SPC / SQC Statistical Process/Quality Control – Quality control in healthcare data.
TIN Tax Identification Number – For billing and reporting.
UCR Usual, Customary, and Reasonable – Cap on payment by insurers.
WC Workers' Compensation – Insurance for job-related injuries.

🔹 I NSURANCE P LAN T YPES

Acrony
Definition
m
ACO Accountable Care Organization – Providers share responsibility and savings.
Consumer-Driven Health Plan – High-deductible plan with health savings
CDHP
account (HSA).
Centers for Medicare & Medicaid Services – Governs federal health
CMS
programs.
Consolidated Omnibus Budget Reconciliation Act – Temporary continued
COBRA
health coverage.
Exclusive Provider Organization – Coverage only in-network (except
EPO
emergencies).
HMO Health Maintenance Organization – Requires PCP and referrals.
IPA Independent Practice Association – Providers who contract with hmos.
MCO Managed Care Organization – Cost-efficient care via HMO, PPO, etc.
POS Point of Service – Combines HMO and PPO features.
PPO Preferred Provider Organization – Flexible, includes out-of-network coverage.
TOP Triple Option Plan – Choice between HMO, PPO, or POS.

SECTION 2: C ODING SYSTEMS O VERVIEW

Overview of ICD-10-CM Guidelines

Introduction to ICD-10-CM
 The ICD-10-CM is a morbidity classification system used in the U.S. for classifying
diagnoses and reasons for visits in healthcare settings.
 It is based on the ICD-10, a global statistical classification of diseases published by the
World Health Organization (WHO).
 The guidelines are developed by the Centers for Medicare and Medicaid Services (CMS)
and the National Center for Health Statistics (NCHS).
 These guidelines are essential for accurate coding and reporting, as they complement
the official ICD-10-CM conventions.
 The guidelines are approved by the Cooperating Parties: AHA, AHIMA, CMS, and NCHS.
 Adherence to these guidelines is required under the Health Insurance Portability and
Accountability Act (HIPAA).
Purpose and Importance of Guidelines

 The guidelines assist healthcare providers and coders in identifying reportable

diagnoses.
 Consistent and complete documentation in medical records is crucial for accurate
coding.
 The term 'encounter' encompasses all healthcare settings, including hospital
admissions.
 The term 'provider' refers to any qualified healthcare practitioner responsible for the
patient's diagnosis.
 The guidelines emphasize the need for a joint effort between healthcare providers and
coders.
 Accurate coding relies on a thorough review of the entire medical record to determine
the reason for the encounter.

Structure of the Guidelines

 The guidelines are organized into sections, each addressing different aspects of
coding.
 Section I covers conventions, general coding guidelines, and chapter-specific
guidelines.
 Section II focuses on the selection of principal diagnoses for non-outpatient settings.
 Section III provides guidelines for reporting additional diagnoses in non-outpatient
settings.
 Section IV is dedicated to outpatient coding and reporting.
 A comprehensive review of all sections is necessary for proper coding.

S ECTION I: C ONVENTIONS AND GENERAL C ODING GUIDELINES

Conventions for the ICD-10-CM

 The conventions include rules for using the Alphabetic Index and Tabular List.
 The format and structure of the coding system are defined to ensure consistency.
 Placeholder characters are used in codes to maintain the correct number of digits.
 The use of 7th characters is essential for certain codes to provide additional specificity.
 Abbreviations are standardized in both the Alphabetic Index and Tabular List.
 Punctuation plays a critical role in the interpretation of codes and their meanings.

Specific Coding Guidelines

 The guidelines specify the use of 'and' to indicate conditions that are related.
 'Other' and 'Unspecified' codes are defined to capture cases where specific information
is not available.
 Inclusion and Exclusion notes clarify which conditions are covered by specific codes.
 Etiology/manifestation conventions guide coders on how to sequence codes for
conditions with multiple causes.
 Default codes are provided for common conditions to simplify coding.
 Clinical criteria must be met for accurate code assignment.
Examples of Coding Conventions
Convention Type Descriptio Example
n Code
Placeholder Used to fill X.0_1
Character in empty
spaces in
codes to
maintain
structure.
 7th Characters Additional A00.0_1
characters
that provide
more detail
about the
diagnosis.
Excludes1 Indicates A00.0
conditions
that are not
included
under a
specific
code.
Etiology/ Guidelines B20
Manifestation for coding
conditions
with
multiple
causes.

Structure and Format of ICD-10-CM

 The ICD-10-CM uses an indented format for ease of reference, allowing coders to
navigate through categories and subcategories efficiently.
 Codes are required for reporting purposes; categories and subcategories alone are not
permissible.
Category Character Descriptio
Type Length n
Category 3 Basic
characters classificatio
n of a
condition
Subcategory 4-5 More
characters specific
classificatio
n
Code 3-7 Final level
characters of detail for
reporting

Use of Codes and Placeholders

 The ICD-10-CM requires the use of a placeholder character 'X' in certain codes to
maintain the structure and allow for future expansion.
 For example, in categories T36-T50 related to poisoning, the 'X' must be included to
validate the code.
 Certain categories require a 7th character, which must be included in the data field; if
not present, the placeholder 'X' is necessary.
 The use of abbreviations such as NEC (Not Elsewhere Classifiable) and NOS (Not
Otherwise Specified) helps coders identify when a specific code is not available.
 Brackets and parentheses are used in the Tabular List to denote synonyms and
nonessential modifiers, respectively.
 Colons indicate that additional modifiers are needed to complete a code.
 S ECTION II: P RINCIPAL DIAGNOSIS SELECTION

Guidelines for Principal Diagnosis

 The principal diagnosis is defined as the condition that is chiefly responsible for the
patient's visit.
 In non-outpatient settings, the guidelines specify how to determine the principal
diagnosis based on the patient's condition.
 The guidelines emphasize the importance of clinical judgment in selecting the principal
diagnosis.
 Documentation must support the selection of the principal diagnosis to ensure
accurate coding.
 The guidelines provide examples of scenarios for selecting the principal diagnosis.
 Coders must be familiar with the specific rules for different types of healthcare
settings.

S ECTION III: R EPORTING ADDITIONAL DIAGNOSES

Guidelines for Additional Diagnoses

 Additional diagnoses are defined as conditions that coexist with the principal diagnosis.
 The guidelines outline when to report additional diagnoses based on their relevance to
the patient's care.
 Documentation must clearly indicate the presence of additional diagnoses to support
coding.
 The guidelines provide criteria for determining the significance of additional diagnoses.
 Examples are provided to illustrate when additional diagnoses should be reported.
 Coders must ensure that all relevant conditions are captured for accurate reporting.

S ECTION IV: O UTPATIENT C ODING AND REPORTING

Outpatient Coding Guidelines

 Outpatient coding differs from inpatient coding in terms of diagnosis selection and
reporting.
 The guidelines specify how to code encounters in outpatient settings, including office
visits and procedures.
 Documentation requirements for outpatient coding are outlined to ensure accuracy.
 The guidelines emphasize the importance of capturing all relevant diagnoses in
outpatient settings.
 Examples of outpatient coding scenarios are provided for clarity.
 Coders must be aware of the specific rules that apply to outpatient coding.

S ECTION IV: D IAGNOSTIC C ODING AND REPORTING GUIDELINES FOR O UTPATIENT SERVICES

Selection of First-Listed Condition

 The first-listed condition is the primary diagnosis that is chiefly responsible for the
patient's visit or encounter.
 Accurate selection of the first-listed condition is crucial for proper coding and
reimbursement.
 Outpatient surgery and observation stays have specific guidelines for determining the
first-listed condition.
  The first-listed condition must be supported by the documentation in the medical
record.
 In cases of multiple conditions, the coder must determine which condition is most
relevant to the encounter.
 The guidelines emphasize the importance of specificity in coding to reflect the
patient's true health status.

Accurate Reporting of ICD-10-CM Diagnosis Codes

 Accurate reporting involves using the correct codes that reflect the patient's diagnosis,
condition, or problem.
 Coders must ensure that all documented conditions that coexist are coded
appropriately.
 The guidelines specify that chronic diseases must be coded in addition to any acute
conditions present.
 For patients receiving diagnostic services only, the coding must reflect the reason for
the encounter without including unrelated conditions.
 The level of detail in coding is essential; codes must be as specific as possible to
ensure proper treatment and reimbursement.
 The guidelines also address encounters for routine health screenings and general
medical examinations with abnormal findings.

Special Considerations in Coding

 Encounters for circumstances other than a disease or injury must be coded accurately
to reflect the reason for the visit.
 Patients receiving therapeutic services only should have their codes reflect the
treatment provided, not just the diagnosis.
 Preoperative evaluations must be coded to indicate the purpose of the visit, which is
distinct from the surgical procedure itself.
 Ambulatory surgery coding requires specific guidelines to ensure that the procedure is
accurately represented.
 Routine outpatient prenatal visits have unique coding requirements to capture the
nature of the care provided.
 The guidelines provide detailed instructions for coding uncertain diagnoses,
emphasizing the need for clarity in documentation.

G ENERAL C ODING GUIDELINES

Locating a Code in the ICD-10-CM

 Understanding the structure of ICD-10-CM codes, which consist of alphanumeric

characters.
 Importance of accurate code selection to ensure proper billing and patient care.
 Use of the index and tabular list for efficient code location.
 Example: Searching for codes related to diabetes mellitus in the index.

Level of Detail in Coding

 Emphasis on specificity in coding to reflect the patient's condition accurately.

 Higher specificity can lead to better patient management and outcomes.
 Example: Coding for type 1 vs. Type 2 diabetes mellitus requires different codes.

Signs and Symptoms

 Guidelines on when to code signs and symptoms versus definitive diagnoses.

  Importance of documenting signs and symptoms for conditions that are not yet
diagnosed.
 Example: Coding for chest pain when the cause is unknown.

Acute and Chronic Conditions

 Differentiation between acute and chronic conditions in coding.

 Guidelines for coding exacerbations of chronic conditions.
 Example: Coding for chronic obstructive pulmonary disease (COPD) with acute
exacerbation.

Combination Codes

 Definition and use of combination codes to capture multiple conditions.

 Benefits of using combination codes for billing and clinical clarity.
 Example: A combination code for diabetes with complications.

CHAPTER -SPECIFIC C ODING GUIDELINES

CHAPTER 1: INFECTIOUS AND PARASITIC DISEASES

 Overview of coding guidelines for infectious diseases.

 Specific codes for HIV infections and their complications.
 Example: Coding for sepsis and its severity levels.

CHAPTER 2: NEOPLASM CLASSIFICATION (C00–D49)

 Organized by site (topography) and behavior:

o Benign
o In situ
o Malignant (primary or secondary)
o Uncertain behavior
o Unspecified behavior
2. Primary vs. Secondary malignancy
 Primary site: original site of malignancy
 Secondary site: metastasis; malignancy has spread
3. Overlapping & multiple neoplasms
 Use .8 for contiguous overlapping lesions (e.g., c16.8 for stomach)
 Use separate codes for non-contiguous tumors
4. Sequencing guidelines
Principal
Encounter type Notes
diagnosis
Primary Except when chemo/radiation →
Primary site treatment
malignancy z51.-

Secondary
Secondary site treatment only Primary is secondary dx
malignancy
Z51.11 / z51.12 /
Chemo/immuno/radiation only Malignancy = secondary dx
z51.0
Inserting radioactive elements Malignancy Do not use z51.0
Extent determination (biopsy) Malignancy site Even if treatment occurs
Pain management G89.3 Neoplasm = secondary dx
Dehydration due to cancer Dehydration Malignancy = secondary
Anemia due to cancer Malignancy D63.0 = secondary
Anemia due to treatment D64.81 + cancer + t-code
 Cancer if still present =
Surgical complication Complication code
secondary
Pathologic fracture (focus:
M84.5 + cancer
fracture)
Pathologic fracture (focus:
Cancer + m84.5
cancer)
5. Historical malignancy (z85 codes)
 Use when:
o Cancer eradicated
o No active treatment directed at that site
6. Encounter for therapy codes
 Z51.0: chemotherapy
 Z51.11: immunotherapy
 Z51.12: radiation therapy
 These are used as principal diagnosis when therapy is the sole reason for
encounter
7. Special cases
 Bia-alcl (breast implant associated anaplastic large cell lymphoma): c84.7a
 Malignancy in transplanted organ: code transplant complication first, then
malignancy
 Secondary lymphoid neoplasms (in extra nodal sites): use c81–c85 codes
8. Important notes
 Reference the neoplasm table and histology terms in the alphabetic index
 Code malignancy of ectopic tissue to the site of origin
 Confirm whether tumors in same organ are new primaries or metastatic
 Determine behavior of neoplasm: benign, malignant, in situ, uncertain, unspecified
9. Visual quick guide: overlapping lesion decision tree
 Tumor overlaps contiguous sites → use .8 overlapping code
 Tumors in non-contiguous sites → assign separate codes
10. Aftercare and follow-up
 Use aftercare and follow-up codes (section i.c.21)
 Continue using malignancy code while treatment is active

🔍 Top Tips for Cancer Coding

Topic Tips
🔁 primary vs Use c7x.x for metastases (secondary cancers). Always code the primary
secondary site first, if known.
Many site-specific codes require right (1), left (2), or bilateral (3). Use
➡️laterality
9 if unspecified.
Icd-10-cm captures behavior only (malignant, in situ, uncertain). Use
🔬 histology types
pathology report for histology.
Use codes d00–d09 (not c codes). These are non-invasive but
❗ in situ neoplasm
precancerous.
Code each distinct primary site, or use combo codes (e.g., c34.80 for
🚨 multiple sites
overlap in lung lobes).
🩸 hematologic C81–c96 = lymphomas, leukemias, myelomas. Usually don’t need
cancers site/laterality.

Neoplasm behavior categories:

Icd-10-cm
Type Description
code prefix
Malignan
C Malignant neoplasm (e.g., c69.50 for malignant lacrimal gland tumor)
t
Benign D Benign neoplasm (e.g., d15.0 for benign lacrimal gland tumor)
Neoplasm that has not spread (non-invasive), but can potentially
In situ D09
become malignant (e.g., d09.20 for lacrimal gland)
 Icd-10-cm
Type Description
code prefix
Unspecifi Neoplasm of unspecified behavior (e.g., d49.89 for unspecified
D49
ed behavior tumor of lacrimal gland)

🚨 Special Coding Situations

1. Evaluation for extent of malignancy: neoplasm (primary or metastatic site) first.

2. Symptoms (e.g., pain, weight loss) linked to cancer: do not replace neoplasm
code.
3. Malignancy complicating pregnancy: o9a.1- first, then neoplasm.
4. Multiple noncontiguous tumors in one organ: query provider.
5. Disseminated malignancy with unknown origin: use c80.0.
6. Malignant neoplasm nos: c80.1, use rarely.
7. Pathologic fractures:
o If focus is fracture: m84.5 first, then neoplasm.
o If focus is neoplasm: neoplasm first, then m84.5.
8. Always specify the behavior
 Use clear terminology:
o Malignant – primary
o Malignant – secondary
o In situ
o Benign
o Uncertain behavior
o Unspecified behavior (only if no other info is available)
❗ avoid vague terms like "mass," "lump," or "lesion" unless further clarified.

9. Clarify cancer origin & spread

 Primary site = where the cancer originated
 Secondary site = metastasis (spread to another location)
Use “to” and “from” in documentation:
ex: “lung cancer metastasized to brain”
→ primary: lung | secondary: brain

10. Include staging & laterality

o TNM or other staging details (if available)
o Laterality: right, left, bilateral
→ required for many neoplasm codes (e.g., breast, lung, kidney)

11. Document current cancer status

Code
Status Notes
type
Active treatment C00-d49 Chemotherapy, surgery, radiation, etc.
No evidence of
Z85.x Personal history of malignant neoplasm
disease (ned)
Follow-up Z08 After cancer treatment completion
Watching a condition without active
Observation only Z51.81
treatment

12. Related conditions

Always document complications or secondary conditions caused by the neoplasm or its
treatment (e.g., anemia due to malignancy, dehydration, cachexia).

13. Special coding scenarios

 Overlapping sites: use subcategory .8
(e.g., c50.81 – overlapping sites of the breast)
  Ectopic malignancy: code to site of origin
(e.g., ectopic pancreas → c25.9)
 Previously excised primary with metastasis:
→ use z85.x for personal history + code for secondary malignancy

14. Neoplasm table usage

Start here when looking up a code:
 By site first (e.g., “breast” → select behavior: malignant/benign/etc.)
 By histologic type, if mentioned (e.g., “adenoma” → see instructions like
“see also neoplasm, by site, benign”)
 Always verify the final code in the tabular list for specificity.

📘 important codes
 Z85.- = personal history of cancer (no current disease)
 C80.0 = disseminated malignancy (no known sites)
 C80.1 = malignant neoplasm, unspecified (rare in inpatient)

🔄 sequencing reminders
 Primary site → secondary site(s) (when treating primary)
 Secondary site → primary site (when treating metastatic site)
 O9a.1- = pregnant with cancer → sequence first, then cancer code

🌿 PRIMARY MALIGNANT NEOPLASM – CODING DECISION TREE

+-------------------------------+
| does the tumor overlap |
| two or more **contiguous** |
| (adjacent) sites? |
+-------------------------------+
|
+----------------+----------------+
| |
Yes no
| |
+----------------------------+ +-------------------------------+
| use code with **.8** | | are the tumors in the same |
| = "overlapping lesion" | | general site but in |
| | | **non-contiguous** locations? |
+----------------------------+ +-------------------------------+
|
+-----------------+----------------+
| |
Yes no
| |
+----------------------------------+ +-----------------------------+
| assign separate codes for each | | use appropriate site-specific|
| tumor location | | code based on documentation |
+----------------------------------+ +-----------------------------+

✅ examples:
 Tumor spans upper and lower stomach → c16.8
 Tumors in upper-outer and lower-inner breast quadrants → assign separate c50.x
codes

Admission/encounter for treatment

 Primary malignancy is principal diagnosis unless chemotherapy or radiation is the

reason for admission.
  Secondary neoplasm is principal diagnosis when treatment is directed at metastasis.

Admission for primary site treatment

 Code the primary malignancy first, unless chemotherapy, immunotherapy, or

radiation is the reason for the visit → use z51.0, z51.11, or z51.12 first.

CHAPTER 4: ENDOCRINE, NUTRITIONAL, AND METABOLIC DISEASES

Introduction To the Endocrine System

 The Endocrine system consists of ductless glands that secrete hormones directly into
the bloodstream, regulating vital body functions and maintaining homeostasis.

 It works in conjunction with the nervous system to ensure balance within the body.

 Key glands include the pituitary, hypothalamus, thyroid, and adrenal glands, among
others.

Distinction between endocrine and exocrine glands

 Endocrine glands secrete hormones into the bloodstream, while exocrine glands have
ducts that release substances onto surfaces (e.g., skin or mucous membranes).

 Examples of exocrine glands include sebaceous, sudoriferous, and salivary glands,

which do not produce hormones.

Structure and function

 The endocrine system consists of ductless glands that secrete hormones directly into
the bloodstream.

 Hormones regulate various body functions, including metabolism, growth, and mood.

 Key glands include the pituitary, thyroid, adrenal, and pancreas, each with specific
hormonal functions.

Common pathologies of the endocrine system

 Adrenal insufficiency occurs when the body fails to produce certain hormones, leading
to fatigue and weakness.

 Cushing’s syndrome is characterized by an overproduction of cortisol, often resulting in

weight gain and high blood pressure.

 Conditions like hyperthyroidism and hypothyroidism involve the overproduction or

underproduction of thyroid hormones, respectively.

Key Anatomy

Gland/
Function/Description
Organ

Pituitary Master Gland That Regulates Other Endocrine

Gland/
Function/Description
Organ

Glands.

Hypothalamu Controls The Pituitary Gland And Regulates

s Homeostasis.

Thyroid Regulates Metabolism And Energy Levels.

Adrenal Produces Hormones Like Cortisol And Adrenaline.

Regulates Blood Sugar Levels Through Insulin

Pancreas
Production.

Produce Female Hormones (Estrogen,

Ovaries
Progesterone).

Testes Produce Male Hormones (Testosterone).

Diseases/conditions

 Adrenal insufficiency: condition where the body fails to produce certain hormones.

 Cushing’s syndrome: overproduction of cortisol by adrenal glands.

 Hyperthyroidism: condition where the body produces too much thyroid hormone.

 Hypothyroidism: condition where the body does not produce enough thyroid
hormone.

 Polycystic ovarian syndrome (PCOS): enlarged ovaries with small cysts.

Key Codes (ICD-10-CM)

Code
Description
Range

E00-E07 Disorders Of Thyroid Gland.

E08-E13 Diabetes Mellitus.

E20-E35 Disorders Of Other Endocrine Glands.

Intraoperative Complications Of Endocrine

E36
System.

E40-E46 Malnutrition.

Key procedures/protocols

 Assigning icd-10-cm codes: steps include searching the alphabetical index, turning
to the tabular index, reading the definition, and identifying the code.
  Assigning cpt codes: involves checking patient status (new/established),
determining the level of history, and identifying procedures performed.

Facts to memorize

 Icd-10-cm codes for endocrine disorders: e00-e89

 Common endocrine pathologies: adrenal insufficiency, Cushing’s syndrome,

hyperthyroidism, hypothyroidism, PCOS

 Cpt code ranges for endocrine procedures: 60000-60699

Concept Comparisons

ICD-10-CM Coding System CPT Coding System

Used For Diagnosis Coding Used For Procedure Coding

Organized By Disease Categories Organized By Types Of Medical Services

Contains Codes For Diseases And Contains Codes For Procedures And Services
Conditions Performed

Example Code: 60650 (Laparoscopic

Example Code: E10.9 (Type 1 Diabetes)
Adrenalectomy)

📌2️⃣TYPES OF DIABETES

 Type 1: Usually Juvenile Onset. Must Be Clearly Documented.

 Type 2: Default If No Type Documented → E11.-

o Type 1: Autoimmune, Juvenile Onset.

o Type 2: Most Common; Insulin Resistance.
o If Not Documented → Default To E11.- (Type 2).

🔹 Diabetes Mellitus (E08–E13) – Guideline I.C.4.A

 Official Source: National Center for Health Statistics (NCHS) – ICD-10-CM

Official Guidelines for Coding And Reporting.
 Excludes1 Note: Chapter 4 Excludes Transient Endocrine/Metabolic Disorders
In Newborns (P70–P74).

COMBINATION CODES

o Combination Codes: Include Type, Body System Affected, And Complications.

o Code Multiple Complications As Needed.
o Sequence Codes Based On Reason For Encounter.

INCLUDE:

o Type Of Diabetes
 o Body System Affected
o Complication(S) Affecting That System
 Assign As Many Codes As Needed To Describe All Complications.
 Sequence Based On Reason For Encounter.

📌 CODING TIPS

 Z79.4: Use For Long-Term Insulin Use (Not For Temporary Use) In Type 2 Or Other
Diabetes (Except Type 1).
 Multiple Codes: Can Be Assigned From E08–E13 As Needed.

USE OF INSULIN & ANTIDIABETIC DRUGS

 Use Z79 Codes To Indicate Long-Term Medication Use:

o Z79.4 – Long-Term Use Of Insulin
o Z79.84 – Long-Term Use Of Oral Hypoglycemics
o Z79.85 – Long-Term Use Of Injectable Non-Insulin Antidiabetics
o Z79.899 – Other Long-Term Drug Therapy (Used When Z79.85 Doesn’t Apply)
 Do Not Assign Z79.4 If Insulin Is Given Temporarily.

DRUG COMBINATION RULES

Medication Combo Codes
Z79.4 +
Insulin + Oral
Z79.84
Insulin + Injectable Non- Z79.4 +
Insulin Z79.85
Oral + Injectable Non- Z79.84 +
Insulin Z79.899

📌 SPECIFIC DIABETES CATEGORIES

📌 PREGNANCY & GESTATIONAL DIABETES

 Coded In Chapter 15 (O24.4-).

 Neonatal Diabetes Is Coded With P70.2.

🔹 DISORDERS OF THYROID GLAND (E00–E07)

Includes:

 Hypothyroidism: often due to thyroid removal, meds, or autoimmune disease.

 Goiter: enlarged thyroid gland.
 Thyrotoxicosis: excess thyroid hormone, not the same as hyperthyroidism.
 Thyroiditis: inflammation, often autoimmune (linked to type 1 diabetes, ra).
🔹 OTHER ENDOCRINE GLANDS (E20–E35)

 Covers parathyroid, pituitary, adrenal, thymus, ovaries/testes.

 Common conditions:
o Cushing’s, addison’s, pcos, premature menopause
o Multiple endocrine neoplasia (men), carcinoid syndrome

🔹 OTHER DISORDERS OF GLUCOSE REGULATION AND PANCREATIC INTERNAL

SECRETION (E15–E16)

 Includes hypoglycemic coma, zollinger-ellison syndrome, unspecified

hypoglycemia.

🔹 MALNUTRITION (E40–E46)

 Severe cases: kwashiorkor, marasmus.

 Codes specify: severe, moderate, mild, or unspecified.
 Related to nutritional deficiency, digestive problems, or medical conditions.

🔹 OTHER NUTRITIONAL DEFICIENCIES (E50–E64)

 Includes vitamin and mineral deficiencies:

o Vitamin a, d, c, b12, iron, calcium, zinc, magnesium, etc.

🔹 OVERWEIGHT, OBESITY, AND OTHER HYPERALIMENTATION (E65–E68)

 Distinguish between overweight, obesity, and morbid obesity.

 Follow instructional notes carefully.

🔹 METABOLIC DISORDERS (E70–E88)

 Common: hyperlipidemia, dehydration, electrolyte imbalance

 Also: cystic fibrosis, metabolic syndrome
 Rare: disorders of fatty acid, amino acid, purine, porphyrin metabolism

🔹 POSTPROCEDURAL ENDOCRINE & METABOLIC COMPLICATIONS (E89)

 For complications from surgery, radiation, or procedures affecting

endocrine/metabolic systems.

DETERMINE TYPE OF DIABETES

Use categories e08–e13:

 E08: due to underlying condition

 E09: drug or chemical induced
  E10: type 1
 E11: type 2 (default)
 E13: other specified

📌 type not specified?

➡ default to e11 (type 2), even if patient is on insulin
➡ dka present? Code as e10 (type 1)

CODE COMPLICATIONS USING 4TH–6TH CHARACTERS

 .0 hyperosmolarity
 .1 ketoacidosis
 .2 kidney complications
 .3 ophthalmic complications
 .4 neurological complications
 .5 circulatory complications
 .6 other specified
 .8 unspecified
 .9 without complications

📌 use as many codes as needed to describe all complications.

🔸 SPECIAL SITUATIONS
🟠 Diabetes In Pregnancy

 See:
o Section I.C.15: Diabetes Mellitus In Pregnancy
o Section I.C.15: Gestational Diabetes

🟠 Insulin Pump Malfunction

 Underdose:
o T85.6- (Pump Failure)
o T38.3X6- (Underdosing)
o Add Diabetes And Complication Codes
 Overdose:
o T85.6- (Pump Failure)
o T38.3X1- (Poisoning, Accidental)
o Add Diabetes And Complication Codes

🔹 Secondary Diabetes (E08, E09, E13)

🔸 E08: Diabetes Due To Underlying Condition

🔸 E09: Drug Or Chemical-Induced Diabetes

🔸 E13: Other Specified Diabetes Mellitus

  Always Caused By Another Condition (E.G., Cystic Fibrosis, Cancer, Surgery, Drug
Reaction).

A. Drug Use In Secondary Diabetes

Follow Same Z79 Coding Rules As Above.

B. Sequencing Rules:

 Follow Tabular List Instructions For E08, E09, E13

 Sequence Based On What’s Driving The Encounter.

🟢 SPECIAL CASE SCENARIOS

(I) Post-Pancreatectomy Diabetes

 E89.1 – Postprocedural Hyperinsulinemia

o E13.- – Other Specified Diabetes Mellitus
o Z90.41- – Acquired Absence Of Pancreas

(Ii) Drug-Induced Diabetes

 Follow Guidelines In:

o Section I.C.19.E (Adverse Effects & Poisoning)
o Section I.C.20 (External Cause Codes)

CHAPTER 5: MENTAL, BEHAVIORAL AND NEURODEVELOPMENTAL DISORDERS

 Guidelines for coding mental health disorders.
 Importance of documenting the relationship between substance use and mental
health.
 Example: coding for depression related to substance abuse.

Mental, behavioral, and neurodevelopmental disorders(f01–f99)

 Outpatient coding often includes depression, anxiety, bipolar disorder.
 Substance use disorders (f10–f19) require distinction between use, abuse,
dependence, and presence of remission.
Objectives of medical coding
 Recognize sections and codes in icd-10-cm and cpt coding manuals related to mental,
behavioral, and neurodevelopmental disorders.
 Describe the sections and codes relevant to these disorders in the coding manuals.
 Apply the process of assigning codes for accurate medical billing.
Overview of icd-10-cm and cpt coding systems
 Icd-10-cm: international classification of diseases, 10th revision, clinical modification,
used for diagnosing diseases.
 Cpt: current procedural terminology, used for coding medical procedures and services.
 Both systems are essential for medical billing and insurance processing.
Mental, behavioral, and neurodevelopmental disorders
Mental disorders
 Defined by symptoms affecting cognitive, emotional, or behavioral functions.
 Disruptions in thinking, behavior, and emotions can lead to significant impairment.
 Examples include anxiety disorders, mood disorders, and psychotic disorders.
Cognitive disorders
 Characterized by impairments in thinking, learning, and memory.
 Can affect various brain regions, leading to specific issues:
 
o Frontal lobe: learning and problem-solving difficulties.
o Temporal lobe: memory problems.
o Parietal lobe: language and speech disorders.
Behavioral disorders
 Persistent patterns of behavior that violate social norms and impair functioning.
 Common in both children and adults, affecting job performance and relationships.
 Examples include adhd, ocd, and conduct disorders.
Neurodevelopmental disorders
 Conditions affecting brain development, leading to behavioral and learning issues.
 Can include autism, learning disabilities, and motor skills disorders.
 Often impact the frontal lobe, affecting communication and social skills.
Icd-10-cm coding system
Structure of icd-10-cm
 Divided into three volumes: anatomical illustrations, alphabetical index, and tabular
index.
 The manual includes an appendix for seventh character codes, which provide
additional detail about diagnoses.
 Codes consist of seven digits, with the first three indicating the category and the last
digit often indicating the extension.
Importance of accurate coding
 Accurate coding is essential for determining medical necessity and preventing claim
denials.
 Ensures that the diagnosis matches the level of specificity required for reimbursement.
 Helps establish a medical history for future providers.
Steps for assigning icd-10-cm codes
 Search the alphabetical index for the medical diagnosis.
 Refer to the tabular index to find the appropriate code.
1. Read the definition of the code and determine if additional characters are needed for
specificity.
Icd-10-cm coding for mental, behavioral, and neurodevelopmental disorders
 The icd-10-cm (international classification of diseases, 10th revision, clinical
modification) is primarily used for coding and classifying mental, behavioral, and
neurodevelopmental disorders, found in chapter 5 (f01-f99).
 This coding system is essential for healthcare providers to document diagnoses
accurately and for billing purposes.
 The codes are organized into categories that reflect different types of disorders,
facilitating easier identification and coding.
Major categories of disorders
 Mental disorders due to known physiological conditions (f01-f09): includes
disorders that are a direct result of physiological issues, such as brain injuries or
diseases.
 Mental and behavioral disorders due to psychoactive substance use (f10-
f19): covers a range of disorders related to substance abuse, including dependence
and withdrawal symptoms.
 Schizophrenia and other non-mood psychotic disorders (f20-f29): encompasses
various psychotic disorders, including schizophrenia and delusional disorders.
Additional categories of disorders
 Mood (affective) disorders (f30-f39): this category includes major depressive
disorder, bipolar disorder, and other mood-related conditions.
 Anxiety and related disorders (f40-f48): covers anxiety disorders, dissociative
disorders, and stress-related disorders.
 Behavioral syndromes (f50-f59): includes eating disorders and other behavioral
syndromes associated with psychological disturbances.
Coding examples for common disorders
 Obsessive-compulsive disorder: to code, search the alphabetic index for
'obsessive-compulsive', leading to f42.9 for unspecified cases.
 Post-traumatic stress disorder: found under 'stress, post-traumatic', coded as
f43.10 for unspecified cases.
 Catatonic schizophrenia: coded as f20.2 after locating 'catatonic' under
'schizophrenia'.
Cpt coding system overview
Introduction to cpt coding
 The current procedural terminology (cpt) is a standardized coding system used to
document medical services and procedures.
 The cpt manual is divided into six sections: evaluation and management,
anesthesiology, surgery, radiology, pathology and laboratory, and medicine.
Breakdown of cpt codes
 Evaluation and management codes (99202-99499): used for services that assess
and monitor patient care.
 Surgical codes (10004-69990): these codes are categorized based on body systems
and surgical procedures performed.
 Radiology codes (70010-79999): cover diagnostic imaging services, including x-
rays and mris.
Importance of accurate coding
 Accurate coding is crucial for analyzing treatment outcomes and ensuring proper
billing.
 It supports research and funding for mental health services, enhancing the quality of
care provided.
 Proper coding helps in maintaining compliance with healthcare regulations.
Steps for assigning cpt codes
 Determine if the patient is new or established, as this affects the coding process.
 Assess the level of history and physical examination performed during the visit.
 Identify each procedure performed and locate the corresponding code in the cpt index.
Practical coding examples
Coding psychotherapy sessions
 For a 30-minute psychotherapy session, search for 'psychotherapy' in the index,
leading to codes 90832-90834.
 The specific code for a 30-minute session is identified as 90832.
Coding developmental screening tests
 To code a developmental screening test, locate 'screening' in the index, leading to
code 96110.
 For additional time spent (30 minutes), use the add-on code 96113.
Coding psychiatric assessments
 For a brief emotional or behavioral assessment, search for 'psychiatric diagnosis' and
find code 96127.
 This code is used for assessments that evaluate emotional and behavioral issues.
Coding for developmental cognitive testing
 For developmental cognitive testing, locate 'developmental cognitive testing' in the
index, leading to codes 96112-96113.
 The first hour of testing is coded as 96112, which includes comprehensive
assessments by a physician.
Key terms/concepts
 Icd-10-cm: the international classification of diseases, 10th revision, clinical
modification, used for coding and classifying diagnoses and health conditions.
 Cpt: current procedural terminology, a medical code set used to report medical,
surgical, and diagnostic procedures and services.
 Mental disorders: conditions characterized by symptoms affecting cognitive,
emotional, or behavioral functions.
 Behavioral disorders: patterns of persistent behavior that violate social norms and
impair functioning.
 Neurodevelopmental disorders: conditions affecting brain development, leading to
difficulties in behavior, learning, and communication.
Key sections of icd-10-cm
Section Description
F01-
Mental disorders due to known physiological conditions
f09
F10-
Mental and behavioral disorders due to psychoactive substance use
f19
F20-
Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders
f29
Section Description
F30-
Mood (affective) disorders
f39
F40- Anxiety, dissociative, stress-related, somatoform, and other nonpsychotic mental
f48 disorders
F50- Behavioral syndromes associated with psychological disturbances and physical
f59 factors
F60-
Disorders of adult personality and behavior
f69
F70-
Intellectual disabilities
f79
F80-
Pervasive and specific developmental disorders
f89
F90- Behavioral and emotional disorders with onset usually occurring in childhood and
f98 adolescence
F99 Unspecified mental disorders
Key steps in assigning icd-10-cm codes
 Search the alphabetical index: look for the medical diagnosis.
 Refer to the tabular index: find the definition of the code.
 Determine if injury or trauma: if applicable, add the seventh character.
 Identify the code: ensure it matches the diagnosis.
Key steps in assigning cpt codes
 Determine patient status: check if the patient is new or established.
 Assess patient history: review the history of present illness and past medical
history.
 Identify procedures: locate each procedure performed from medical documentation.
 Use the index: find the specific procedure code in the corresponding section.
Key cpt codes for mental health services
Code type Description
90832-
Individual psychotherapy codes for 30 minutes
90834
96110 Code for developmental screening
96127 Code for brief emotional/behavioral assessment
Code for developmental cognitive testing by a physician for the
96112
first hour
Facts to memorize
 Icd-10-cm codes for mental disorders: f01-f99
 Cpt codes for evaluation and management: 99202-99499
 Cpt codes for psychotherapy sessions: 90832-90834, 90836-90838
 Cpt codes for developmental screening: 96110, 96113
 Cpt code for brief emotional/behavioral assessment: 96127
Concept comparisons
Concept Icd-10-cm coding system Cpt coding system
Classifies diseases and conditions for Codes medical services and
Purpose
diagnosis procedures
Seven-digit codes with categories, Six sections including evaluation,
Structure
subcategories, etc. surgery, etc.
Used for insurance claims and medical
Use in billing Used for billing services rendered
necessity
Example of
F42.9 (obsessive-compulsive disorder) 90832 (psychotherapy, 30 minutes)
codes

Special Coding Considerations

Documentation by Clinicians Other than the Patient's Provider
 Guidelines on how documentation from other healthcare providers affects coding.
 Importance of accurate and complete documentation for coding integrity.
  Example: Coding based on referrals from specialists.
Use of Z Codes
 Definition and application of Z codes in coding.
 Importance of Z codes for capturing social determinants of health.
 Example: Coding for a patient with a history of substance use disorder.
Coding for Healthcare Encounters in Hurricane Aftermath
 Guidelines for coding encounters related to natural disasters.
 Use of external cause codes to document the impact of disasters on health.
 Example: Coding for injuries sustained during a hurricane evacuation.
Chapter Overview

Mental and Behavioral Disorders

 This section covers disorders resulting from psychoactive substance use, emphasizing
the impact on mental health.
 It includes diagnostic criteria and coding guidelines for various substance-related
disorders.
 Case studies illustrate the complexities of diagnosing and coding these disorders.
 Historical context: The evolution of understanding mental health and substance use
disorders over the decades.
 Importance of accurate coding for treatment and insurance purposes.

Diseases of the Nervous System

 Discusses conditions affecting the nervous system, including dominant/nondominant
side considerations.
 Pain management is categorized under G89, detailing coding for pain-related
diagnoses.
 Examples of common neurological disorders and their coding implications.
 Historical references to the development of neurological diagnostics and treatments.
 Emphasis on the importance of precise coding for effective patient management.

Diseases of the Eye and Adnexa

 Focuses on conditions such as glaucoma and blindness, including their prevalence and
impact on quality of life.
 Coding guidelines for eye diseases, including specific codes for various stages and
types of glaucoma.
 Case studies highlighting the importance of early diagnosis and intervention.
 Historical context of eye disease treatment and advancements in ophthalmology.
 The role of coding in facilitating research and funding for eye health initiatives.

Diseases of the Circulatory System

 Covers a range of conditions including hypertension, coronary artery disease, and
myocardial infarction.
 Detailed coding guidelines for each condition, emphasizing the importance of accurate
documentation.
 Case studies demonstrating the impact of cardiovascular diseases on public health.
 Historical context: The rise of cardiovascular diseases as a leading cause of mortality.
 Discussion on the implications of coding for treatment protocols and insurance
reimbursements.

Diseases Of the Circulatory System (I00–I99) – Complete Study Guide

🔹 CATEGORIES OVERVIEW
Code
Category
Range
I00–I02 Acute Rheumatic Fever
I05–I09 Chronic Rheumatic Heart Diseases
I10–I15 Hypertensive Diseases
I20–I25 Ischemic Heart Diseases
I26–I28 Pulmonary Heart Disease
 I30–I52 Other Forms Of Heart Disease
I60–I69 Cerebrovascular Diseases
Diseases Of Arteries, Arterioles &
I70–I79
Capillaries
Diseases Of Veins, Lymphatic Vessels &
I80–I89
Nodes
Other & Unspecified Circulatory
I95–I99
Disorders
🩺 KEY CODING GUIDELINES
1️⃣HYPERTENSION (HTN) CODING (I10–I16)
 I10: Essential (Primary) Hypertension – No Heart/Kidney Involvement.
 I11.-: Hypertensive Heart Disease – Add I50.- For Specific HF Type.
 I12.-: HTN With CKD – Add N18.- For CKD Stage.
 I13.-: HTN With Heart Disease & CKD – Add I50.- And N18.-
 I15.-: Secondary HTN – Code Underlying Cause First. Use Z92.21 If Long-Term HTN
Med Use.
 I16.-: Hypertensive Crisis – Urgency/Emergency; Add HTN Type.
💡 suggestions:
 Memorize the coding hierarchy for htn + heart + kidney conditions.
 Always check for causal linkage in provider notes (e.g., "due to hypertension").
2️⃣HEART FAILURE (I50.-)
Type Code
Unspecified I50.9
Left Heart Failure I50.1
I50.2
Systolic Heart Failure
-
I50.3
Diastolic Heart Failure
-
Combined Systolic & I50.4
Diastolic -
💡 Suggestions:
 Look For Terms Like "Ejection Fraction" In Clinical Notes To Support Systolic/Diastolic
Classification.
 Identify Acuity (Acute, Chronic, Acute On Chronic) To Code To Highest Specificity.
3️⃣CEREBROVASCULAR ACCIDENT (CVA)
 Hemorrhagic Stroke: I60–I62
 Ischemic Stroke: I63
 Sequelae (Residuals): I69.-
💡 Suggestions:
 Use I69.- For Deficits Like Hemiplegia, Dysphagia, Aphasia.
 Dominant Vs. Nondominant Side Matters In Hemiplegia/Paresis Codes.
 Document If CVA Is Intraoperative/Postprocedural (Use I97.81/I97.82 + Stroke Code).
4️⃣ISCHEMIC HEART DISEASE (I20–I25)
 I25.2: Old MI, No Treatment Needed.
 I21.-: Acute MI (Within 4 Weeks)
 I22.-: Subsequent MI (Within 4 Weeks)
 I21.A1/A9: Type 2, 4, 5 MI
💡 Suggestions:
 Sequence AMI (I21) Before CAD (I25) If Both Are Present.
 Identify MI Type: STEMI (I21.0-I21.3), NSTEMI (I21.4)
 STEMI Always Trumps NSTEMI In Conversion.
5️⃣ATHEROSCLEROSIS & ANGINA (I25.-)
 I25.11-: Native Artery Atherosclerosis With Angina (Combo Code)
 I25.7-: With Bypass Graft/Transplant Vessel
💡 Suggestions:
 Do Not Separately Code Angina When Using Combination Atherosclerosis Codes.
6️⃣SEQUELAE OF CVA (I69.-)
 I69.- + Deficit Type
 Use Z86.73 For History Of CVA Without Residuals
💡 Suggestions:
 Always Pair I69 With Specifics: Hemiplegia, Aphasia, Etc.
 Determine Side And Dominance To Use Correct Code.
7️⃣ANESTHESIA CPT® CODES FOR CARDIAC PROCEDURES
CPT
Description
Code
Heart/Great Vessel Surgery W/O
00560
CPB
Heart/Great Vessel Surgery W/
00561
CPB
00562 Valve/Complex Surgery W/ CPB
00563 Complex CPB W/ Hypothermia
00566 Heart Transplant (Recipient)
Heart-Lung Transplant
00567
(Recipient)
00580 Pacemaker Or AICD Insertion
➕ Add-On Codes:
 36620: Arterial Line Placement
 36555–36556: Central Line Placement (Age-Based)
 99100–99140: Qualifying Circumstances (E.G., Extreme Age)
 P1–P6: Physical Status Modifiers
 AA, QX, QZ, QK: HCPCS Anesthesia Modifiers
💡 Suggestions:
 Document CPB Usage, Hypothermia, And Physical Status Clearly.
 Only Bill Separately For Central/Arterial Lines If Distinctly Documented And Not
Included In Global Package.
🧠 GENERAL CODING REMINDERS
✅ Always Capture Severity, Laterality, And Complications.
✅ Code To Highest Specificity.
✅ Review Tabular Notes For sequencing and additional code instructions.
✅ use z-codes for history, status (e.g., z95.1 for pacemaker).
✅ confirm if mi occurred during or after a procedure (impacting code selection).
✅ always check for linkage statements (e.g., "due to hypertension").
Hypertensive Diseases Coding Tip Sheet
Note: This Is Not An All-Inclusive List. Refer To The ICD-10-CM Manual For A Full List Of Codes.

Chronic Kidney Disease (CKD) Stages

Stag
Description Code
e
1 CKD Stage 1 N18.1
2 CKD Stage 2 (Mild)N18.2
CKD Stage 3 N18.3
3
(Moderate) 0
N18.3
3a CKD Stage 3a
1
N18.3
3b CKD Stage 3b
2
4 CKD Stage 4 (Severe) N18.4
5 CKD Stage 5 N18.5
End-Stage Renal
ESRD N18.6
Disease
Dialysis Dependent Z99.2

Hypertension Codes
Condition Notes Code
Essential (Primary) Hypertension I10
Also Code Type Of Heart
Hypertensive Heart Disease
Failure
Condition Notes Code
– With Heart Failure I11.0
– Without Heart Failure I11.9
Hypertensive CKD Also Code CKD Stage
– With Stage 5 CKD Or ESRD I12.0
– With Stage 1–4 Or Unspecified CKD I12.9
Also Code HF Type + CKD
Hypertensive Heart And CKD
Stage
– With HF And Stage 1–4 CKD Or
I13.0
Unspecified
– With HF And Stage 5 CKD Or ESRD I13.2
– Without HF, With Stage 1–4 CKD Or I13.1
Unspecified 0
I13.1
– Without HF, With Stage 5 CKD Or ESRD
1

Secondary Hypertension
Note Cod
Type
s e
Renovascular Hypertension I15.0
Due To Other Renal Disorders I15.1
Due To Endocrine Disorders I15.2
Other Secondary Hypertension I15.8
Secondary Hypertension,
I15.9
Unspecified

Hypertensive Crisis
Also Code I10–I15 Cod
Type
Diagnosis e
Hypertensive Urgency I16.0
Hypertensive Emergency I16.1
Hypertensive Crisis,
I16.9
Unspecified

Additional codes for tobacco use/exposure

Description Code
Exposure to environmental tobacco
Z77.22
smoke
Occupational exposure to tobacco
Z57.31
smoke
Tobacco use Z72.0
History of tobacco dependence Z87.891
F17.** (specify
Tobacco dependence
subtype)

Heart failure coding

Type Code

Left ventricular failure, unspecified I50.1

Unspecified systolic hf I50.20

Acute systolic hf I50.21

Type Code

Chronic systolic hf I50.22

Acute on chronic systolic hf I50.23

Unspecified diastolic hf I50.30

Acute diastolic hf I50.31

Chronic diastolic hf I50.32

Acute on chronic diastolic hf I50.33

Combined systolic & diastolic hf –

I50.40
unspecified
– acute I50.41
– chronic I50.42
– acute on chronic I50.43

Right hf – unspecified I50.810

– acute I50.811

– chronic I50.812

– acute on chronic I50.813

Right hf due to left hf Also, code left ventricular failure

Also code type

Biventricular hf
(systolic/diastolic/combined)

High output hf I50.83

End stage hf Also code hf type

Other hf I50.89

Heart failure, unspecified I50.9

Diseases of the respiratory system

 Discusses chronic obstructive pulmonary disease (copd), asthma, and acute
respiratory failure.
 Coding guidelines for respiratory conditions, including specific codes for complications
like ventilator-associated pneumonia.
 Case studies illustrating the management of respiratory diseases in clinical settings.
 Historical references to the understanding and treatment of respiratory diseases over
time.
 Importance of coding in tracking disease prevalence and guiding public health
initiatives.
Introduction to respiratory system coding
Objectives of the study guide
 Identify sections and codes related to the respiratory system in icd-10-cm and cpt
coding manuals.
 Examine the sections and codes related to the respiratory system in icd-10-cm and cpt
coding manuals.
 Asthma classification: mild intermittent, mild persistent, moderate persistent, severe
persistent, etc.
 Copd, bronchitis, emphysema often have combination codes with acute exacerbation.
 Pneumonia: identify organism if known (e.g., j15.0 pneumonia due to klebsiella).
 Apply the process of assigning codes relevant to the respiratory system.
Overview of the respiratory system
 The respiratory system is responsible for the process of breathing, taking in oxygen
and removing carbon dioxide.
 It is essential for ensuring that tissues of all other body systems can operate with
oxygen.
 Works closely with the cardiovascular system to ensure blood is oxygenated,
highlighting the interdependence of body systems.
Anatomy of the respiratory system
 Upper respiratory tract: includes the nasal cavity, pharynx, and larynx.
 Lower respiratory tract: comprises the trachea, bronchi, bronchioles, alveoli, and
pleura, which are crucial for gas exchange.
Common pathologies and procedures
Common respiratory pathologies
 Cystic fibrosis: characterized by thick, viscous secretions mainly in the lungs, leading
to severe respiratory issues.
 Asthma: involves inflammatory responses in the respiratory tract, causing difficulty in
breathing.
 Pneumonia: an infection deep in the lung tissue, often requiring hospitalization.
 Bronchitis: an infection in the bronchi, leading to coughing and mucus production.
 Copd: chronic obstructive pulmonary disease, a progressive lung disease that
obstructs airflow.
Common respiratory procedures
 Rhinoplasty: a surgical procedure commonly referred to as a 'nose job'.
 Vats: video-assisted thoracoscopic surgery, a minimally invasive surgical technique.
 Spirometry: a test that measures the rate and strength of breath, essential for
diagnosing respiratory conditions.
 Cpap machine: continuous positive airway pressure ventilation used for patients with
sleep apnea.
 Ventilator management: involves the insertion and use of ventilators for patients
who cannot breathe independently.
Icd-10-cm coding system
Overview of icd-10-cm
 The icd-10-cm is the international classification of diseases, 10th revision, clinical
modification, used universally in medical and insurance industries.
 It provides a comprehensive listing of diseases and codes necessary for billing and
insurance processing.
Structure of icd-10-cm manual
 The manual is divided into three volumes: anatomical illustrations, alphabetical index,
and tabular index.
 Anatomical illustrations: aid in understanding the location of body parts.
 Alphabetical index: a list of main terms or keywords to help find the appropriate
code.
 Tabular index: organized by body systems, providing a systematic approach to
coding.
Coding format and components
 The icd-10-cm consists of seven possible digits: the first three digits indicate the
category, followed by a dot and additional digits for subcategories and extensions.
 The last digit may indicate the extension, which is not required for all codes.
Assigning codes in icd-10-cm
Importance of accurate coding
 Accurate coding is necessary to determine medical necessity and prevent insurance
claim rejections.
 It helps establish a medical history of a diagnosis, allowing future providers to
understand past treatments.
Steps for assigning icd-10-cm codes
 Search the alphabetical index for the medical diagnosis.
 Turn to the tabular index to find the relevant code.
 Read the definition of the code to ensure accuracy.
 Determine if the diagnosis is an injury or trauma; if so, add the seventh character if
applicable.
 Identify the correct code, ensuring it matches the level and specificity of the cpt code.
Icd-10-cm overview
Introduction to icd-10-cm
 The icd-10-cm (international classification of diseases, 10th revision, clinical
modification) is primarily used for coding and classifying diseases and health
conditions.
 Chapter 10 specifically addresses diseases of the respiratory system, covering codes
j00 to j99.
 This coding system is essential for healthcare providers to document diagnoses
accurately for billing and statistical purposes.
Key codes in respiratory system
 Acute upper respiratory infections (j00-j06): includes common colds and other
acute infections affecting the upper respiratory tract.
 Influenza and pneumonia (j09-j18): covers various types of influenza and
pneumonia, critical for understanding seasonal illnesses.
 Chronic lower respiratory diseases (j40-j47): encompasses conditions like chronic
bronchitis and emphysema, significant for chronic care management.
Additional respiratory codes
 Lung diseases due to external agents (j60-j70): addresses conditions caused by
environmental factors, such as asbestosis.
 Intraoperative and postprocedural complications (j95): important for coding
complications arising during or after surgical procedures.
 Other diseases of the respiratory system (j96-j99): a catch-all category for less
common respiratory conditions.
Icd-10-cm coding examples
Coding acute bronchitis
 Step 1: search the alphabetic index for the term 'bronchitis'.
 Step 2: locate 'acute' in the subheadings.
 Code: j20.9 is identified for acute bronchitis, unspecified.
Coding mild persistent asthma
 Step 1: search for 'asthma' in the alphabetic index.
 Step 2: find 'mild persistent' in the subheadings.
 Code: j45.30 is assigned for mild persistent asthma, nos.
Coding upper respiratory infection
 Step 1: search for 'infection' in the alphabetic index.
 Step 2: locate 'respiratory' and 'upper' in the subheadings.
 Code: j06.0 is designated for acute upper respiratory infection, unspecified.
Cpt coding system
Overview of cpt coding
 The current procedural terminology (cpt) is a standardized coding system used for
reporting medical services and procedures.
 The manual is divided into six sections: evaluation and management, anesthesiology,
surgery, radiology, pathology and laboratory, and medicine.
Key components of cpt codes
 Evaluation and management codes (99202-99499): used for patient assessment
and monitoring.
 Surgical codes (30000-32999): specific to procedures performed on the respiratory
system, such as surgeries on the nose, larynx, and lungs.
 Radiology codes (70010-79999): cover diagnostic imaging services, crucial for
respiratory assessments.
Assigning cpt codes
Importance of accurate coding
 Accurate coding is essential for analyzing treatment outcomes and ensuring proper
reimbursement.
 It supports research and funding initiatives in healthcare.
1. Proper coding enhances efficiency in reporting and billing processes.
Steps in assigning cpt codes
2. Determine if the patient is new or established to select the appropriate coding level.
3. Assess the level of history and physical examination performed during the visit.
4. Identify each procedure performed and locate the corresponding code in the cpt index.
Understanding cpt modifiers
5. Cpt modifiers provide additional information about the procedure performed, affecting
reimbursement.
 Two types of modifiers exist: functional (impacting payment) and informational
(providing statistical data).
Key terms/concepts
 Icd-10-cm: the international classification of diseases, 10th revision, clinical
modification, used for coding diseases and health conditions.
 Cpt: current procedural terminology, a medical code set used to report medical,
surgical, and diagnostic services.
 Bronchitis: inflammation of the bronchi, often resulting in cough and mucus
production.
 Spirometry: a common test used to assess how well the lungs work by measuring
how much air one inhales, exhales, and how quickly.
 Cpap: continuous positive airway pressure, a treatment for obstructive sleep apnea
that uses a machine to deliver air pressure.
Key procedures
Procedure Description
Surgical procedure to change the shape of the nose, often referred to as a
Rhinoplasty
"nose job."
Video assisted thoracotomy surgery; a minimally invasive surgical
Vats
technique used to access the chest cavity.
A test that measures the rate and strength of breath to assess lung
Spirometry
function.
A device that provides continuous positive airway pressure to assist with
Cpap
breathing during sleep.
Ventilator Involves the insertion and use of ventilators to assist patients with
management breathing.
Diseases/conditions
 Cystic fibrosis: a genetic disorder that causes thick, sticky mucus to build up in the
lungs and digestive system.
 Asthma: a condition characterized by inflammatory responses in the respiratory tract,
leading to difficulty breathing.
 Pneumonia: an infection that inflames the air sacs in one or both lungs, which may fill
with fluid.
 Bronchitis: an infection in the bronchi that causes coughing and mucus production.
 Copd: chronic obstructive pulmonary disease, a group of lung diseases that block
airflow and make it difficult to breathe.
Key codes (icd-10-cm)
Code
Description
range
J00-j06 Acute upper respiratory infections
J09-j18 Influenza and pneumonia
J20-j22 Other acute lower respiratory infections
J30-j39 Other diseases of upper respiratory tract
J40-j47 Chronic lower respiratory diseases
J60-j70 Lung diseases due to external agents
J80-j84 Other respiratory diseases principally affecting the interstitium
 Code
Description
range
J85-j86 Suppurative and necrotic conditions of the lower respiratory tract
J90-j94 Other diseases of the pleura
Intraoperative and postprocedural complications and disorders of respiratory system,
J95
not elsewhere classified
J96-j99 Other diseases of the respiratory system.
Key Steps In Assigning Codes
 ICD-10-CM:
o Search the alphabetical index for the medical diagnosis.
o Turn to the tabular index.
o Read the definition of the code.
o Determine if the diagnosis is an injury or trauma; if yes, add the seventh
character if applicable.
o Identify the code.
 Cpt:
o Check if the patient is new or established.
o Determine the level of history and physical exam.
o Identify each procedure performed from the medical documentation.
o Use the index to locate the specific procedure.
o Find the code in the corresponding section.
Facts to memorize
 Icd-10-cm codes for respiratory system: j00-j99
 Cpt codes for respiratory procedures: 30000-32999
 Common respiratory pathologies: cystic fibrosis, asthma, pneumonia, bronchitis, copd
 Common respiratory procedures: rhinoplasty, vats, spirometry, cpap, ventilator
management
Concept comparisons
Concept Icd-10-cm Cpt
Codes medical procedures and
Purpose Classifies diseases and conditions
services
Three volumes (anatomical, alphabetical, Six sections (evaluation, surgery,
Structure
tabular) etc.)
Code
Seven digits (e.g., j20.9) Five digits (e.g., 30410)
format
Use Diagnosis coding for insurance Procedure coding for billing

Detailed coding guidelines

Pregnancy, childbirth, and the puerperium

 General rules for coding obstetric cases, including the selection of principal diagnoses.
 Detailed coding for pre-existing conditions versus those arising from pregnancy.
 Case studies on managing complications during pregnancy, such as diabetes and
hypertension.
 Historical context of maternal health and the evolution of obstetric care.
 Importance of accurate coding for maternal and fetal health outcomes.

Certain conditions originating in the perinatal period

 Guidelines for coding conditions that arise during the perinatal period, including
prematurity and low birth weight.
 Emphasis on the observation and evaluation of newborns for suspected conditions.
 Case studies highlighting the significance of early intervention in perinatal care.
 Historical references to advancements in neonatal care and outcomes over the years.
 The role of coding in improving perinatal health statistics and research.
 Chapter 16: newborn conditions
Bacterial sepsis of newborn
 Bacterial sepsis is a severe infection in newborns that can lead to systemic
inflammation and organ dysfunction.
 Common pathogens include group b streptococcus and e. Coli, which can be
transmitted during delivery.
 Symptoms may include lethargy, poor feeding, and temperature instability.
 Early diagnosis and treatment with antibiotics are crucial for improving outcomes.
 Case studies show that timely intervention can reduce mortality rates significantly.
 Prevention strategies include screening pregnant women for risk factors and
administering prophylactic antibiotics.
Stillbirth
 Stillbirth refers to the loss of a fetus at or after 20 weeks of gestation.
 Risk factors include maternal health issues, infections, and placental problems.
 Emotional and psychological impacts on parents can be profound, necessitating
support services.
 Investigations post-stillbirth may include autopsy and placental examination to
determine causes.
 Public health initiatives aim to reduce stillbirth rates through education and prenatal
care.
 Historical data indicates a decline in stillbirth rates due to improved maternal care
practices.
Covid-19 infection in newborn
 Newborns can contract covid-19, primarily through maternal transmission during
pregnancy or delivery.
 Symptoms in newborns may be mild or absent, but severe cases can lead to
respiratory distress.
 Studies indicate that breastfeeding may provide some level of immunity to infants.
 Guidelines recommend monitoring newborns for symptoms and providing supportive
care as needed.
 Vaccination of pregnant individuals is encouraged to reduce transmission risk.
 Ongoing research is essential to understand long-term effects of covid-19 on newborn
health.

Chapter 18: symptoms, signs, and abnormal findings

Use of symptom codes
 Symptom codes are used to classify conditions that are not yet diagnosed.
 They provide essential information for treatment and research purposes.
 Accurate coding is crucial for healthcare reimbursement and statistical analysis.
 Example: a patient presenting with chest pain may be coded for the symptom until a
definitive diagnosis is made.
 Guidelines emphasize the importance of using symptom codes in conjunction with
definitive diagnosis codes.
 Case studies highlight the impact of accurate symptom coding on patient
management.
Combination codes
 Combination codes are used to represent multiple conditions or a condition with
associated symptoms.
 They simplify coding and reduce the number of codes needed for billing.
 Example: a combination code may include both diabetes and its complications,
streamlining the coding process.
 Understanding combination codes is essential for accurate documentation and billing.
 The use of combination codes can improve data quality for epidemiological studies.
 Training on combination codes is recommended for coding professionals to enhance
accuracy.
Specific conditions and their codes
 Repeated falls can indicate underlying health issues, necessitating thorough
evaluation.
 Coma coding requires precise documentation of the cause and duration of the coma.
  Functional quadriplegia coding reflects the impact of neurological conditions on
mobility.
 Sirs (systemic inflammatory response syndrome) due to non-infectious processes must
be accurately coded to reflect the underlying cause.
 Death nos (not otherwise specified) codes are used when the cause of death is unclear.
 The nihss (national institutes of health stroke scale) is a standardized tool for assessing
stroke severity.

Medical coding systems for the reproductive system

Icd-10-cm coding system overview
 The icd-10-cm (international classification of diseases, 10th revision, clinical
modification) is a universal coding system used in medical and insurance industries to
classify diseases and conditions.
 It is essential for insurance claims processing, where the diagnosis code must match
the cpt code for services rendered.
Structure of icd-10-cm codes
 The coding manual is divided into three volumes: anatomical illustrations, an
alphabetical index, and a tabular index, aiding in code identification.
 Each code consists of seven digits: the first three indicate the category, followed by a
dot, and the remaining digits specify subcategories and extensions.
Assigning icd-10-cm codes
 The process involves searching the alphabetical index for the medical diagnosis,
referencing the tabular index, and reading the code definitions.
 It is crucial to determine if the diagnosis is an injury or trauma, as this may require
adding a seventh character for specificity.
Icd-10-cm overview for reproductive system
Chapter 14: diseases of the genitourinary system
 This chapter includes codes n00-n99, covering various diseases affecting the
genitourinary system.

 Key categories include glomerular diseases (n00-n08), renal tubulo-interstitial
diseases (n10-n16), and acute kidney failure (n17-n19).
o Urolithiasis (n20-n23) and other disorders of the kidney and ureter (n25-n29)
are also included.
o The chapter provides a comprehensive framework for coding diseases related
to the urinary system and reproductive organs.
o Understanding these codes is crucial for accurate medical billing and treatment
analysis.
o Example: glomerular diseases can lead to significant renal impairment,
necessitating precise coding for effective treatment.
Chapter 15: pregnancy, childbirth, and the puerperium
 This chapter encompasses codes o00-o9a, focusing on conditions related to pregnancy
and childbirth.
o Key codes include o00-o08 for pregnancy with abortive outcomes and o09 for
supervision of high-risk pregnancies.
o Maternal disorders predominantly related to pregnancy are coded from o20-
o29, addressing complications that may arise during gestation.
o Understanding these codes is essential for maternal-fetal medicine and
obstetric care.
o Example: hypertensive disorders in pregnancy (o10-o16) can significantly
affect maternal and fetal health, requiring careful monitoring and coding.
o Accurate coding in this chapter supports better healthcare outcomes and
resource allocation.
Coding examples in icd-10-cm
 Coding for abdominal ectopic pregnancy involves searching the alphabetic index for
'pregnancy' and locating 'ectopic, abdominal' to find code o00.00.

o For undescended testicle, the process includes searching for 'undescended'
and locating 'testicle' leading to code q53.9.
 o Diffuse cystic mastopathy is coded by searching for 'mastopathy' and locating
'cystic' to identify code n60.1.
o Acute oophoritis is coded by searching for 'oophoritis' and locating 'acute' to
find code n70.02.
o These examples illustrate the systematic approach required for accurate
coding in medical documentation.
o Understanding the coding process enhances the ability to navigate complex
medical records efficiently.
CPT Coding System Overview
Structure Of The CPT Manual
 The CPT Manual Is Divided Into Six Sections: Evaluation And Management,
Anesthesiology, Surgery, Radiology, Pathology And Laboratory, And Medicine.

o Each Section Contains Specific Codes That Correspond To Various Medical
Services And Procedures.
o Understanding The Structure Is Essential For Accurate Coding And Billing In
Medical Practices.
o Example: Evaluation And Management Codes (99202-99499) Are Crucial For
Documenting Patient Visits And Care Management.
o Anesthesia Codes (00100-01999) Represent The Use Of Anesthesia During
Surgical Procedures, Highlighting The Importance Of Accurate Documentation.
o Familiarity With The Manual's Structure Aids In Efficient Coding Practices.
Surgery Codes In The CPT System
 Surgery Codes For The Male Genital System Range From 54000-55980, Covering
Procedures Related To The Penis, Testis, And Prostate.
o Female Genital System Surgery Codes (56405-58999) Include Procedures For
The Vulva, Vagina, Cervix, And Ovaries.
o Maternity Care And Delivery Codes (59000-59899) Encompass Antepartum,
Delivery, And Postpartum Care Procedures.
o Understanding These Codes Is Vital For Obstetricians And Gynecologists To
Ensure Accurate Billing And Patient Care.
o Example: In Vitro Fertilization Procedures Are Coded From 58970-58999,
Reflecting The Complexity Of Reproductive Technologies.
o Accurate Coding In Surgery Is Essential For Reimbursement And Tracking
Treatment Outcomes.
Assigning CPT Codes
 Assigning CPT Codes Involves Checking If A Patient Is New Or Established And
Determining The Level Of History And Physical Exam.

o The Process Includes Identifying Each Procedure Performed And Using The
Index To Locate The Specific Procedure Code.
o Special Situations, Such As Multiple Procedures Or Locations, Require Careful
Attention To Ensure Accurate Coding.
o CPT Modifiers Provide Additional Information About The Procedure, Affecting
Reimbursement And Documentation.
o Example: Functional Modifiers Impact Medicare And Medicaid Reimbursements,
While Informational Modifiers Provide Statistical Data.
o Mastery Of The Coding Process Enhances The Accuracy And Efficiency Of
Medical Billing.
Key Anatomy
Male Reproductive System Components
Component Description
External
Includes Penis And Scrotum
Genitalia
Internal Includes Vas Deferens, Seminal Vesicles, Prostate Gland,
Genitalia Bulbourethral Glands
Female Reproductive System Components
 Component Description
External Includes Mons Pubis, Labia, Bartholin’s Glands,
Genitalia Clitoris
Internal Includes Vagina, Uterus, Cervix, Fallopian Tubes,
Genitalia Ovaries
Key Pathologies
Common Male Pathologies
Pathology Description
Benign Prostate Noncancerous Growth Of The Prostate Gland, Common In
Hyperplasia Elderly Males
Gynecomastia Increase In Breast Tissue Due To Hormonal Imbalance
Hypospadias Urethra Opening On The Underside Of The Penis
Orchitis Inflammation Of One Or Both Testicles
Torsion Of Testes Twisting Of The Spermatic Cord
Common Female Pathologies
Pathology Description
Dysfunctional Uterine Bleeding Abnormal Bleeding Outside Of The Normal Menstrual
(DUB) Cycle
Endometriosis Inner Lining Of The Uterus Grows Outside The Uterus
Fibroids Non-Cancerous Tumors In The Uterus
Key Coding Systems
ICD-10-CM Coding System
 Chapter 14: Diseases Of The Genitourinary System (N00-N99)
 Chapter 15: Pregnancy, Childbirth, And The Puerperium (O00-O9A)
CPT Coding System
 Sections: Evaluation And Management, Anesthesiology, Surgery, Radiology, Pathology
And Laboratory, Medicine
 Surgery Codes: Male Genital System (54000-55980), Female Genital System (56405-
58999), Maternity Care And Delivery (59000-59899)
Facts To Memorize
 ICD-10-CM Codes For Reproductive System: N00-N99 (Genitourinary System) And O00-
O9A (Pregnancy, Childbirth, And Puerperium).
 CPT Codes For Male Genital System: 54000-55980.
 CPT Codes For Female Genital System: 56405-58999.
 CPT Codes For Maternity Care And Delivery: 59000-59899.
Concept Comparisons
Concept ICD-10-CM CPT
Purpose Classifies Diseases And Conditions Codes Medical Procedures And Services
Structur Alphanumeric Codes With Up To 7
Numeric Codes, Primarily 5 Digits
e Characters
Diagnosis Coding For Insurance And Medical Procedure Coding For Billing And
Use
Records Documentation
Cause And Effect
Cause Effect
Benign Prostate
Noncancerous Growth Of The Prostate Gland, Common In Elderly Males
Hyperplasia
Inner Lining Of The Uterus Grows Outside Of The Uterus, Causing Pain
Endometriosis
And Complications
Sexually Transmitted Infection Affecting Both Males And Females, Can
Gonorrhea
Lead To Serious Health Issues If Untreated.

Chapter 19: Injury and Poisoning

Application of 7th Characters
 The 7th character is used in injury coding to provide additional information about the
encounter.
  It indicates the episode of care, such as initial, subsequent, or sequela.
 Accurate application of 7th characters is essential for proper coding and
reimbursement.
 Example: A fracture may require different codes based on whether it is the initial
treatment or a follow-up visit.
 Training on the use of 7th characters can enhance coding accuracy and compliance.
 Case studies demonstrate the importance of correct 7th character application in injury
coding.
Coding of Injuries
 Injury coding involves classifying various types of injuries, including fractures, burns,
and lacerations.
 Each type of injury has specific codes that reflect the nature and severity of the injury.
 Accurate coding is crucial for treatment planning and insurance reimbursement.
 Example: Coding for traumatic fractures requires detailed documentation of the type
and location of the fracture.
 The use of external cause codes can provide context for the injury, such as the
mechanism of injury.
 Continuous education on injury coding is necessary to keep up with updates in coding
guidelines.
Adverse Effects and Complications
 Adverse effects, poisoning, and underdosing must be accurately coded to reflect
patient safety issues.
 Example: A patient experiencing an adverse reaction to medication requires specific
coding to track safety concerns.
 Understanding the difference between adverse effects and complications is essential
for accurate coding.
 Case studies highlight the importance of documenting adverse effects for quality
improvement initiatives.
 Coding for child and adult abuse requires sensitivity and adherence to legal guidelines.
 Continuous training on coding for adverse effects is recommended for healthcare
professionals.

Chapter 20: External Causes of Morbidity

General External Cause Coding Guidelines
 External cause codes are used to classify the circumstances surrounding injuries and
health conditions.
 They provide valuable data for public health and safety initiatives.
 Example: Coding for motor vehicle accidents includes details about the type of
accident and the involved parties.
 Accurate external cause coding is essential for understanding injury patterns and
prevention strategies.
 Guidelines emphasize the importance of using external cause codes in conjunction
with injury codes.
 Training on external cause coding can enhance data quality for research and policy-
making.
Place of Occurrence and Activity Codes
 Place of occurrence codes indicate where an injury or health condition occurred, such
as home, workplace, or public space.
 Activity codes describe what the individual was doing at the time of the incident,
providing context for the injury.
 Accurate documentation of place and activity is crucial for understanding injury trends.
 Example: A fall at work may require different coding than a fall at home, impacting
safety regulations.
 Guidelines recommend using place and activity codes to enhance the specificity of
external cause coding.
 Continuous education on these codes is necessary for accurate reporting and analysis.
Chapter 21: Factors Influencing Health Status
Use of Z Codes
  Z codes are used to indicate factors influencing health status and encounters with
healthcare services.
 They provide additional information about the patient's health context, such as social
determinants of health.
 Example: A Z code may indicate a patient's lack of access to healthcare resources,
impacting treatment plans.
 Accurate use of Z codes is essential for comprehensive patient documentation and
care planning.
 Guidelines emphasize the importance of integrating Z codes into routine coding
practices.
 Training on Z codes can enhance understanding of their role in patient care and health
outcomes.
Categories of Z Codes
 Z codes are categorized into various groups, including those for encounters for routine
examinations, vaccinations, and follow-up care.
 Each category has specific codes that reflect the purpose of the encounter.
 Example: A Z code for a routine check-up may differ from one for a follow-up after
surgery.
 Understanding the categories of Z codes is crucial for accurate coding and billing.
 Continuous education on Z codes can improve coding accuracy and patient care.
 Case studies demonstrate the impact of Z codes on healthcare delivery and outcomes.

ICD-10-CM Coder's Compliance Checklist: Key Guidelines

1. Confirm Diagnosis or Use Signs/Symptoms

 Definitive Diagnosis: Code the documented condition (e.g., J45.909 for asthma).
 Signs/Symptoms: Use if no diagnosis is confirmed (e.g., R05 for cough).
 Specificity: Ensure details like laterality (e.g., M17.11 for right knee osteoarthritis) or
organism (e.g., A41.51 for E. Coli sepsis).
 Review Entire Record: Look for clues in progress notes, lab results, or imaging.

2. Integral vs. Non-Integral Signs/Symptoms

 Integral: Do not code symptoms inherent to the diagnosis (e.g., dyspnea in
pneumonia).
 Non-Integral: Code separately if unrelated (e.g., R21 for rash in a diabetic patient).

3. Multiple Coding for Single Conditions

 Etiology + Manifestation:
o Example: E11.9 (Type 2 diabetes) + N18.3 (chronic kidney disease).
 Infections: Code both condition (J15.9, pneumonia) and organism
(B96.2, Staphylococcus).
 Sequencing: Follow "Code First" or "Use Additional Code" instructions in the Tabular
List.

4. Acute and Chronic Conditions

 Code Both: Sequence acute first (e.g., K80.20 [acute cholecystitis]
+ K80.10 [chronic cholecystitis]).
 Applies Only: When both are documented as coexisting.

5. Combination Codes
 Single Code: Use when a code captures both diagnosis and complication
(e.g., O24.419 [gestational diabetes with hypoglycemia]).
  Avoid Duplication: Do not split into separate codes if a combination code exists.

6. Sequela (Late Effects)

 Current Condition First:
o Example: R13.1 (dysphagia) + I69.391 (sequela of stroke).
 Exception: Use G81.94 (hemiplegia) if the sequela code includes the manifestation.

7. Impending or Threatened Conditions

 Threatened: Use specific codes if listed (e.g., O60.03 for threatened preterm labor).
 Not Listed: Code symptoms (e.g., R10.9 for abdominal pain if "impending
appendicitis" is undocumented).

8. Reporting the Same Code More Than Once

 Bilateral Conditions: Use M17.0 (bilateral knee osteoarthritis) or M17.11 (right)
+ M17.12 (left).
 Avoid Duplicates: Each code is reported once per encounter.

9. Laterality
 Specificity: Use M25.561 (right knee pain) or M25.562 (left).
 Unspecified: Use M25.569 (unspecified knee pain) only if laterality is undocumented.

10. Documentation by Other Clinicians

 Allowed: BMI (Z68.1), pressure ulcer stage (L89.154), coma scale (R40.24).
 Diagnosis: Must be confirmed by a qualified provider (e.g., I10 for hypertension).

11. Syndromes
 No Code?: Code manifestations (e.g., R50.9 [fever] + R21 [rash] for undiagnosed
viral syndrome).

12. Complications of Care

 Link Required: Code T81.12XA (postoperative hematoma) if the provider documents
it as a complication.
 Significance: Must impact care (e.g., K91.3 [postoperative ileus]).

13. Borderline Diagnoses

 Code as Confirmed: Unless a "borderline" code exists (e.g., R79.8 for borderline
cholesterol).
 Query Provider: If documentation is unclear.

14. Sign/Symptom/Unspecified Codes

 Acceptable: R55 (syncope) if cause is unknown.
 Avoid Assumptions: Never code I21.9 (acute MI) without confirmation.

15. Hurricane Aftermath Coding

 Injury First: S42.001A (fractured humerus) + X37.0 (hurricane).
  Z Codes: Add Z59.0 (homelessness) or Z99.12 (ventilator dependency during
outage).

Key Takeaways
 Specificity: Prioritize detailed codes (e.g., laterality, organism).
 Documentation: Ensure provider notes justify codes (e.g., "acute and chronic"
conditions).
 Compliance: Follow "Code First," "Use Additional Code," and sequencing rules.
 Ethics: Never assign codes without documentation or order unnecessary tests

Coding Acute and Chronic Conditions in ICD-10-CM

1. Definitions
 Acute Conditions: Sudden onset, short duration (e.g., pneumonia, fracture).
 Chronic Conditions: Long-lasting, persistent, or recurring (e.g., diabetes,
hypertension).

2. Documentation Requirements
 Provider Clarity: Acute/chronic status must be explicitly documented by the provider.
 Query if Unclear: If documentation is ambiguous (e.g., "bronchitis" without specifying
acute/chronic), seek clarification.

3. Combination Codes
 When Available: Use a single code if it captures both acute and chronic aspects
(e.g., K80.20 for acute-on-chronic cholecystitis).
 No Combination Code: Code both acute and chronic separately (e.g., J44.1 [chronic
obstructive pulmonary disease with acute exacerbation] + J44.9 [chronic COPD]).

4. Sequencing Rules
 Reason for Encounter:
o Acute First: If the visit focuses on treating the acute condition
(e.g., I10 [hypertension] + N17.9 [acute kidney injury]).
o Chronic First: If managing the chronic condition (e.g., E11.9 [Type 2
diabetes] as primary for a routine check-up).
 Exacerbations: Code the acute exacerbation of a chronic condition first
(e.g., J44.1 [COPD with acute exacerbation]).

5. Additional Codes
 Chronic as Secondary: Include chronic conditions if they impact care
(e.g., E11.9 [diabetes] as secondary for a foot ulcer).
 Exclusions: Do not code chronic conditions unrelated to the encounter.

6. Sequela vs. Chronic

 Sequela (Late Effects): Code residuals of past acute conditions (e.g., I69.3 [sequela
of stroke] for residual paralysis).
 Chronic: Ongoing, active conditions (e.g., I25.10 [chronic ischemic heart disease]).

7. Special Cases
 "History of": Use Z codes (e.g., Z86.79 for history of myocardial infarction) if the
condition is resolved but impacts care.
 Asthma: Differentiate between J45.901 (acute exacerbation) and J45.40 (chronic
persistent asthma).

How to Determine Which to Code

1. Review Documentation: Identify if the provider specifies acute, chronic, or both.
 2. Check for Combination Codes: Use if available (e.g., K70.30 [alcoholic cirrhosis
with acute alcoholic hepatitis]).
3. Sequence Appropriately:
o Acute first if it’s the reason for the visit.
o Chronic first if managing the chronic condition.
4. Code Both When Applicable: If both are present and relevant
(e.g., I10 [hypertension] + N17.9 [acute kidney injury]).
5. Follow Guidelines: Refer to ICD-10-CM Chapter-specific guidelines (e.g., Chapter 9
for circulatory conditions).

Examples
Scenario ICD-10-CM Codes

Acute Exacerbation
of COPD J44.1 (COPD with acute exacerbation) as primary.

Routine Diabetes
Management E11.9 (Type 2 diabetes) as primary.

Chronic Kidney N17.9 (acute kidney injury) + N18.9 (chronic kidney disease),
Disease with AKI sequence by encounter focus.

Key Takeaways
 Specificity is Critical: Always prioritize provider documentation and ICD-10-CM
guidelines.
 Avoid Assumptions: Do not infer acute/chronic status without explicit
documentation.
 Query Providers: Clarify ambiguous terms like "recurrent" vs. "chronic."
By adhering to these principles, coders ensure accurate reimbursement, compliance, and data
integrity.

This checklist ensures accurate, compliant coding and reduces audit risks. Always cross-
reference the ICD-10-CM Index and Tabular List

✅ ICD-10-PCS Official Coding Guidelines Summary

✅ Root Operations Breakdown

Root
Definition Examples Coding Tips
Operation
Cutting Out/Off Without
Lumpectomy, Liver Use Qualifier To Specify
Excision Replacement Of A Portion Of A
Biopsy Biopsy If Appropriate
Body Part
Resection Removes
Total Lobectomy,
Resection Cutting Out/Off All Of A Body Part Entire Body Part, Not
Total Nephrectomy
Just A Portion
Use When Objective Is
Taking Or Letting Out Fluids/Gases Abscess Drainage,
Drainage To Remove Fluid, Not
From A Body Part Thoracentesis
Tissue
Dilation & Curettage Use When The Method
Pulling Out/Off All/Portion Of A
Extraction (D&C), Tooth Involves Pulling Out With
Body Part By Force
Extraction Force
Putting In A Non-Biological Device Central Line Check Device And
Insertion That Monitors/Supports Body Placement, Approach Details For
Function Pacemaker Insertion Accuracy
Replaceme Putting In New Biological/Synthetic Hip Replacement, Verify Body Part
nt Material To Replace A Body Part Corneal Transplant Replaced And Material
 Root
Definition Examples Coding Tips
Operation
Type
Ensure All (Intended)
Joining Body Parts Together To Spinal Fusion, Ankle
Fusion Body Parts Listed Are
Render Immobile Fusion
Being Fused

A. Conventions

 Characters: ICD-10-PCS Codes Are Composed of Seven Alphanumeric

Characters, Each Representing a Specific Axis of Classification.
 No Decimals or Placeholders Like In ICD-10-CM.
 "No Qualifier" (Z) Or "No Device" (Z) Is Used When Applicable.
 All Seven Characters Must Be Specified; A Valid Code Must Have All Positions
Filled.

📚 B2. Body System Guidelines

 Root Operation: Determine The Objective of The Procedure (E.G., Excision,

Resection, Fusion, Etc.).
 Body Part: Choose The Body Part Based on The Operative Report and The PCS
Table.
 Approach: Examples Include Open, Percutaneous, Percutaneous Endoscopic.
 Multiple Procedures: Code Each If:
o Different Root Operations Are Performed On The Same Body Part.
o Same Root Operation But Different Body Parts.
o Multiple Procedures Via Separate Incisions Or Approaches.
 Bilateral Procedures: If There’s A Specific Bilateral Body Part Value, Assign One
Code. If Not, Assign Separate Codes For Left And Right.
 Discontinued Procedures: If The Procedure Is Not Completed, Code The
Portion That Was Performed. No Specific Code For "Aborted" Procedures
Exists.

B2.1a - Anatomical Regions Vs. Specific Body Parts

 Use Anatomical Regions (General, Upper, Lower Extremities) When:
o The Procedure Is Done On A Region, Not A Specific Part.
o Specific Body Part Info Is Not Documented.
 Examples:
o Chest Tube: Drainage, Anatomical Regions, General.
o Abdominal Wall Suture: Repair, Anatomical Regions, General.
o Foot Amputation: Detachment, Anatomical Regions, Lower Extremities.
B2.1b - “Upper” And “Lower” Designations
 Refers To Above Or Below Diaphragm In:
o Arteries
o Veins
o Muscles
o Tendons
 Example: Jugular Vein = Upper Veins; Femoral Vein = Lower Veins.

🔍 B3. Root Operation Guidelines

B3.1a - Root Operation Selection
 Use The PCS Table Definition For Choosing Correct Root Operation.
B3.1b - Integral Steps
 Do Not Code Separately:
o Approaches (E.G., Laparotomy).
o Site Closure.
o Anastomosis (Unless It’s The Main Intent).
  Example: Resection During Joint Replacement Is Part Of Replacement.

🔁 B3.2 - Multiple Procedures

Code Multiple Procedures When:
 ✅ Same Root Op On Different Body Parts
o Ex: Excision Of Liver & Pancreas.
 ✅ Same Root Op On Multiple, Distinct Body Parts Within One PCS Value
o Ex: Excision Of Sartorius & Gracilis (Upper Leg Muscle).
 ✅ Different Root Ops On Same Body Part
o Ex: Destruction + Bypass Of Sigmoid Colon.
 ✅ Converted Approach
o Ex: Lap Chole → Open = Code Both Approach Attempts.

⛔ B3.3 - Incomplete Procedures

 Code What Was Actually Done.
 If Stopped Before Any Root Op → Inspection.
 Example: Aortic Valve Replacement Stopped After Thoracotomy = Inspection Of
Mediastinum.

🔬 B3.4 - Biopsy Procedures

B3.4a - Biopsy = Excision / Extraction / Drainage + Diagnostic Qualifier
 Lung FNA → Drainage, Diagnostic.
 Bone Marrow → Extraction, Diagnostic.
 Lymph Node → Excision, Diagnostic.
B3.4b - Biopsy + Treatment = Code Both
 Ex: Breast Biopsy + Partial Mastectomy = Code Both.

🧱 B3.5 - Overlapping Body Layers

 Code Deepest Layer.
 Ex: Debridement Of Skin, Subq, And Muscle → Code To Muscle.

🔁 B3.6 - Bypass Guidelines

B3.6a - General Bypass
 Body Part = "From", Qualifier = "To".
 Ex: Stomach To Jejunum → Stomach (Body Part), Jejunum (Qualifier).
B3.6b - Coronary Artery Bypass
 Body Part = # Of Arteries "To".
 Qualifier = "From" Vessel (E.G., Aorta).
B3.6c - Multi-Coronary Bypass
 Code Each Different Device And/Or Qualifier Separately.
 Ex: Aortocoronary + IMA Bypass = 2 Codes.

🩸 B3.7 - Control Vs. Specific Root Ops

 Control = Stop Acute/Post-Op Bleeding Not Better Defined Elsewhere.
 Use Occlusion, Excision, Etc., If More Specific.
 Ex:
o Nasal Cautery → Control.
o Embolization → Occlusion.
o Suctioning Blood During Cryobiopsy = Integral, Not Coded Separately.
✂️B3.8 - Excision Vs. Resection
 Resection = 100% Of The Body Part.
 Excision = Partial Removal.
 Ex: Left Upper Lung Lobectomy = Resection, Not Excision Of Lung.

🧬 B3.9 - Excision For Graft

 If Graft Source Is Different Site, Code It Unless:
o The Qualifier Already Specifies The Harvest Site.
 Ex: Saphenous Vein Harvest = Coded Separately.
o DIEP Flap = Not Coded Separately (Specified In Qualifier).

🧷 B3.10 - Spinal Fusion

B3.10a
 Code Based On Level: Cervical, Thoracic, Lumbar, Etc.
B3.10b
 Multiple Vertebral Joints = Separate Code If:
o Different Device Or Qualifier Used.
B3.10c
 If Combo Devices Used On Same Joint:
o Use Appropriate Device Code (Follow Table Hierarchy).
CD-10-PCS Coding Guidelines Cheat Sheet: Body Part, Approach, And Device

B4. BODY PART GENERAL GUIDELINES

B4.1a – Portion Of Body Part

Code To The Whole-Body Part If The Portion Doesn't Have A Separate Value.
Example: Alveolar Process Of Mandible → Mandible Body Part.

B4.1b – "Peri" Prefix

If "Peri" Is Used And Not Further Specified, Code To The Named Body Part.
Examples:
 Perirenal → Kidney
 Peri-Urethral In Vulvar Tissue → Vulva
 Periosteum → Corresponding Bone

B4.1c – Vascular Procedures On Continuous Sections

Code To The Most Proximal (Closest To Heart) Vessel.
Example: Femoral To External Iliac Artery → External Iliac Artery

B4.2 – Branches Of Body Parts

Code To The Proximal Branch With Its Own Value.
Examples:
 Mandibular Branch → Trigeminal Nerve
 Bronchial Artery → Upper Artery (Not Thoracic Aorta)

B4.3 – Bilateral Body Parts

Use Bilateral Value If Available. If Not, Code Each Side Separately.
Examples:
 Bilateral Fallopian Tube Procedure → One Code
 Bilateral Knees → Two Codes

B4.4 – Coronary Arteries

Treated As A Single Body Part, Specified By Number Of Arteries Treated. Examples:
 Two Arteries, Both Stented → One Code With Two Arteries & Devices
  One Artery With Stent, One Without → Two Separate Codes

B4.5 – Tendons, Ligaments, Bursae, Fascia Near Joints

Code To Structure's System Unless It’s Joint-Specific.
Examples:
 ACL Repair → Knee Bursae/Ligament System
 Cartilage Shaving → Lower Joints System (Knee)

B4.6 – Skin/Subcutaneous/Fascia Over Joints

Code To Regional Limb Part:
 Shoulder → Upper Arm
 Elbow/Wrist → Lower Arm
 Hip → Upper Leg
 Knee → Lower Leg
 Ankle → Foot

B4.7 – Fingers And Toes

If No Finger/Toe Value, Code To Hand/Foot.
Example: Excision Of Finger Muscle → Hand Muscle

B4.8 – Upper/Lower Intestinal Tract

For Certain Root Operations (Change, Insertion, Etc.):
 Upper Tract: Esophagus To Duodenum
 Lower Tract: Jejunum To Anus
Example: Change Of Jejunal Device → Lower Intestinal Tract

B5. APPROACH

B5.2a – Open With Percutaneous Endoscopic Assistance

Code To Open.
Example: Laparoscopic-Assisted Sigmoidectomy → Open

B5.2b – Percutaneous Endoscopic With Hand-Assist Or Incision Extension

Code To Percutaneous Endoscopic.
Examples:
 Hand-Assisted Laparoscopic Colectomy With Colon Exteriorization
 Laparoscopic Nephrectomy With Midline Incision

B5.3a – External (Visible Without Instrument)

Example: Tonsillectomy → External

B5.3b – External Force Through Layers

Example: Closed Fracture Reduction → External

B5.4 – Percutaneous Via Device

Example: Stone Fragmentation Via Nephrostomy → Percutaneous

B6. DEVICE GUIDELINES

B6.1a – Device Coded Only If It Remains

If Removed During The Same Procedure, Code Both Insertion And Removal.
B6.1b – Not Coded As Device: Sutures, Ligatures, Markers, Temporary Drains.
B6.1c – Procedure On Device Only
Use Change, Irrigation, Removal, Or Revision Root Operations.
Example: Irrigation Of Nephrostomy Tube → Administration Section

B6.2 – Drainage Devices

Insertion Of A Drain → Root Operation Drainage, Device Value = Drainage Device

C. Root Operation Guidelines

 Biopsy: Considered A Separate Procedure Even If Performed With Another More

Definitive Procedure.
 Excision Vs. Resection:
o Excision: Portion Of A Body Part.
o Resection: Entire Body Part.
 Drainage: Can Include Aspiration Or Fluid Removal.
 Fusion: Spinal Fusion Procedures Must Include The Approach, Device, And Level.
 Bypass: Clarify The Source And Destination Of Flow; Commonly Used In
Cardiovascular Procedures.

Obstetrics Section

C1. Products Of Conception

 Code Procedures On The Products Of Conception In The Obstetrics Section.
 Code Procedures On The Pregnant Female (Not Involving POC) In The Medical And
Surgical Section.
Examples:
 Amniocentesis → Obstetrics Section, Body Part: Products Of Conception
 Repair Of Obstetric Urethral Laceration → Medical/Surgical Section, Body Part: Urethra

C2. Postpartum/Abortion Procedures

 Post-Delivery/Abortion Curettage or Evacuation of Retained POC →
Obstetrics Section, Root Operation: Extraction, Body Part: Products Of Conception,
Retained
 D&C During Non-Postpartum/Abortion Times →
Medical/Surgical Section, Root Operation: Extraction, Body Part: Endometrium

D. Body System Guidelines

 Skin And Subcutaneous Tissue: Pay Attention To Depth (E.G., Drainage Of Skin Vs.
Muscle).
 Muscles, Tendons, And Bones: Procedures Involving Reposition, Release, Or Repair
Are Coded Based On Specific Anatomic Detail.

D1.A. Brachytherapy Coding

Brachytherapy Procedure → Radiation Therapy Section, Modality: Brachytherapy
 If Radioactive Source Is Implanted and Left In Body, Also Code:
o Medical/Surgical Section → Root Operation: Insertion
o Device: Radioactive Element
Special Implants (Single Code Only):
 Cesium-131 Collagen Implant
 Palladium-103 Collagen Implant
→ Code To Insertion With Specific Radioactive Element Implant As Device.
D1.B. Brachytherapy Applicators
 Temporary Applicator Placed Separately:
→ Insertion With Device: Other Device
 Applicator Placed During Brachytherapy Procedure:
→ Single Brachytherapy Code (Radiation Therapy Section)

E. Approach Guidelines

 Approaches Include:
o Open
o Percutaneous
o Percutaneous Endoscopic
o Via Natural Or Artificial Opening
o Via Natural Or Artificial Opening Endoscopic
o Via Opening With Percutaneous Endoscopic Assistance
o External

F. Device Guidelines

 A Device Is Coded Only If It Remains After The Procedure.

 Removal Of A Device Requires A Separate Procedure Code.
 Types Include: Internal Fixation, Pacemaker Leads, Drains, Grafts, Stents.

G. Qualifier Guidelines

 Qualifiers Provide Additional Information Like Graft Types, Bypass Destinations, Or

Types Of Transplantation.

🔍 Overview Of CPT® Coding Guidelines

1.1 CPT® Code Structure

• Category I Codes: Procedural Codes Used Most Commonly.

• Category II Codes: Performance Measurement (Optional).

• Category III Codes: Temporary Codes For Emerging Technologies.

1.2 CPT® Conventions & Symbols

• Bullet (•) = New Code

• Triangle (▲) = Revised Code

• + = Add-On Code (Must Be Reported With Primary Code)

• ● = Telemedicine Services

• (Separate Procedure) = Typically Included in A More Comprehensive Code When

Performed at The Same Encounter
🔍 Step-By-Step Coding Workflow

2.1 Pre-Coding

1. Review Documentation: Confirm Documentation Supports Medical Necessity,

Location, Provider, And Service Rendered.

2. Identify Key Components:

• Date Of Service

• Place Of Service (POS)

• Provider Specialty

• Patient Status (New/Established, Inpatient/Outpatient)

• Payer Information

2.2 Code Assignment

3. Determine Main Procedure/Service:

• Use The CPT Index to Look Up Main Terms and Sub Terms.

• Verify Full Code Description in the CPT Manual.

4. Check For Add-On or Modifier Use:

• Example: 96375 (Therapeutic, Add-On IV Push) Must Be Paired With

96365 Or Other Initial Code.

5. Apply Modifiers as Needed:

• -25: Significant, Separately Identifiable E/M Service On Same Day As A

Procedure

• -59: Distinct Procedural Service

• -51: Multiple Procedures

• -76: Repeat Procedure By Same Provider

6. Link Diagnosis Codes: Match The CPT®/HCPCS Codes To Appropriate ICD-10-CM

Codes To Justify The Service.

🔍 National Correct Coding Initiative (NCCI) Edits

3.1 Purpose

• Prevent Improper Coding and Unbundling.

• Ensure Services Reported Together Are Appropriately Distinct.

3.2 Understanding NCCI Edits

• Column 1/Column 2 Pairs: Column 2 Is Usually Bundled Into Column 1.

 • Modifiers Allowed? Check The NCCI Manual Or CMS Tables. If “Y”, Modifier
May Be Used To Bypass Edit With Justification.

Example:

• 45385 (Colonoscopy With Polypectomy)

• 45380 (Colonoscopy With Biopsy)

• Edit Present (Cannot Report Both Unless Documentation Supports Two Distinct
Lesions/Procedures And Modifier -59 Is Used Appropriately).

3.3 Use of Modifier -59 Or X{EPSU} Modifiers

• XE: Separate Encounter

• XS: Separate Structure

• XP: Separate Practitioner

• XU: Unusual Non-Overlapping Service

🔍 Payer-Specific Coding Guidance

4.1 Medicare Guidelines (CMS)

• Strict Adherence To NCCI Edits

• Requires:

• Medical Necessity Per LCD/NCD

• Global Surgical Package Rules (0-, 10-, 90-Day Periods)

• No “Incident-To” For New Problems or If Non-Physician

Provider Changes Plan

• Modifier -25 Scrutiny: Documentation Must Justify Distinct E/M

Service.

• MUE (Medically Unlikely Edits): Check CMS Limits Per Line of

Service.

Example: Medicare Billing for Skin Lesion Removal

• CPT 17000 (Destruction of Premalignant Lesions)

• MUE: 15 Units

• Must Have Corresponding ICD-10 Like D48.5

4.2 Commercial Payers (E.G., BCBS, UHC, Aetna)

• May Have:

• Customized Bundling Rules

• Preauthorization Requirements
 • Less Restrictive Use Of -25

• Variations In Telehealth Coverage

• Site-Of-Service And Coverage Variations

Tip: Always Check Individual Payer Policies Via Portals or Coding Bulletins.

🔍 Common Coding Scenarios with NCCI Edits

Service CPT NCCI Modifier
Coding Tip
Combination Codes Edit Allowed
Office Visit with 99213 + No -25 May Be Only If E/M Is Separately Identifiable
Minor Procedure 11721 Edit Needed and Well Documented
Injection And 99214 + No Clearly Document Separate Purpose
-25 If Unrelated
E/M 96372 Edit for The Office Visit
Colonoscopy W/ 45380 + Use Modifier When Biopsy And
Yes Yes (-59 Or XS)
Biopsy & Snare 45385 Polypectomy Are At Distinct Sites
Simple Repair Is Bundled Unless
Lesion Removal 11402 +
Yes Yes (-59) Performed At A Separate Site or
& Repair 12001
Intent

📘 Parent Vs. Child Codes In CPT® Coding

🔹 1. Parent Code

 The Parent Code Is the Primary CPT Code That Represents A Comprehensive Service
Or Procedure.

 It Typically Describes the Main Procedure and May Encompass Related, Bundled
Services.

 The Parent Code Is Often Listed with A Full Description and Is Required to Interpret
Related Add-On or Child Codes.

 Example:
17000 – Destruction Of Premalignant Lesion; First Lesion

🔹 2. Child Code (Add-On or Component Code)

 The Child Code Is a Related, Dependent Code That Cannot Be Reported

Without the Parent Code.

 It May Represent:

o An Additional Component of a Procedure

o An Add-On Service Performed with The Parent Code

 Child Codes Often Appear Indented Under a Parent Code in The CPT Book.

 Example:
17003 – ... Each Additional 14 Lesions (List Separately in Addition to Code for First
Lesion)

o Must Be Used With 17000.

 ✅ Examples of Parent-Child Code Relationships

Parent Code Child/Add-On Code Use Case

17003 – Each
17000 – Destruction Of
Additional 14 Add-On Code For Multiple Lesions
First Lesion
Lesions

11045 – Each
11042 – Debridement,
Additional 20 Sq Add-On For Wound Area
First 20 Sq Cm
Cm

+76942 – US Guidance Imaging Is Billed Separately With

20610 – Joint Injection
For Injection Modifier If Not Bundled

69210 – Earwax May Be Separately Reported If Distinct

99213 – E/M Visit
Removal From E/M (Use Modifier -25)

🛑 Important Coding Rules

 Never Bill a Child Code Alone – It Must Follow A Parent.

 Use Modifier -25 If The E/M Service (Parent) Is Significant and Separately
Identifiable from The Procedure (Child).

 Always Check NCCI Edits To Confirm Whether Codes Can Be Billed Together.

 Refer To CPT Guidelines and Payer Policies To Verify Bundling Rules.

✅ Parent Vs. Child CPT Codes Quick Summary

 Parent Code: Main, Comprehensive Procedure Or Service.

 Child Code: Subset Of Parent, Often Bundled (Not Separately Billable Unless Distinct).

 Bundling Rules: Follow NCCI Edits + Payer Policy.

 Modifiers May Allow Separate Reimbursement When Criteria Are Met.

🧠 Anesthesia Coding Study Guide (CPT®, Modifiers, Units, And Scenarios)

General Guidelines:

 Services Include: General, Regional, Local Supplementation, Monitored Anesthesia

Care (MAC)

 Reported By or Under Physician Supervision

o Preoperative & Postoperative Visits

o Intraoperative Monitoring (E.G., ECG, BP, Oximetry)

o Administration Of Fluids/Blood

o Anesthesia Care During Procedure

 Used For: General, Regional, Local Supplementation, And Monitored Anesthesia Care
(MAC)
🧑‍⚕️Who Can Report?

 Reported By or Under the Supervision of a Physician

 Services Include:

o Preoperative And Postoperative Visits

o Monitoring (E.G., ECG, BP, Oximetry, Capnography)

o Administration Of Fluids/Blood

o Intraoperative Care

🔑 1. Anesthesia CPT® Code Ranges

• 00100–01999 – Anesthesia Codes By Anatomic Site

• 99100–99140 – Qualifying Circumstances (Add-On Codes)
• 01990–01992 – Other Procedures (E.G., Burn Dressing, Central Circulation
Assistance)
• 99151–99157 – Moderate Sedation

🔁 2. Anesthesia Time Reporting

🕒 Time Units:

 Based On 15-Minute Increments

 1 Time Unit = Every 15 Minutes Of Anesthesia

📝 Start Time: Begins When the Anesthesiologist Starts Preparing The Patient
📝 End Time: Ends When the Anesthesiologist Is No Longer Personally Attending the
Patient
🔄 Multiple Procedures

 Report The Most Complex Anesthesia Code

 Total Time = Combined Time for All Procedures

💉 Moderate (Conscious) Sedation

 Not Reported with Codes 00100–01999

 Codes For Sedation:

o Same Physician Performing Procedure + Sedation: 99151–99153

o Second Physician In Facility Setting: 99155–99157

o Not Reportable In Nonfacility Settings By A Second Physician

Modifier 47: Use When A Surgeon Provides Regional/General Anesthesia (Not Anesthesia
Provider)
 🧮 3. Anesthesia Reimbursement Formula

Total Units = Base Units + Time Units + Modifying Units

Then:

Total Reimbursement = Total Units × Conversion Factor

🧠 Anesthesia Reimbursement & Modifier

💵 Anesthesia Reimbursement Formula

Total Units = Base Units + Time Units + Modifying Units

Payment = Total Units × Conversion Factor (CF)

✅ Step 1: Base Units

CPT® Codes 00100–01999 = Anesthesia Services

o Each Procedure Has An Assigned Base Unit Based on Complexity

o Found In the ASA Relative Value Guide® (RVG) Or CMS Anesthesia Crosswalk

📌 Example:
00102 – Anesthesia for Cleft Lip Repair = 5 Base Units

✅ Step 2: Time Units

• Anesthesia Begins with Preparation and Ends When Personal Care Ends
• 1 Time Unit = 15 Minutes (E.G., 90 Min ÷ 15 = 6 Units)
• Rounding Varies By Payer Policy

📌 Example:
90 Minutes → 6-Time Units

✅ Step 3: Modifying Units

Additional Units For Risk, Status, Or Special Circumstances:

Modifier(S Unit
Type Description
) s

Physical
P1–P6 P3 = Severe Systemic Disease 0–3
Status

Qualifying 99100– Age <1yr (99100), Emergency Varie

Circ. 99140 (99140) s
 📌 Example:
P3 = 1 Unit, 99100 = 1 Unit

✅ Step 4: Conversion Factor

• Dollar Amount Per Unit Set By Payer (E.G., Medicare = ~$22.00/Unit)

• Varies By Region, Year, And Payer

📌 Example:
CF = $22.00
Total Units = 10 → 10 × $22.00 = $220

🧮 Example Payment Calculation

Component Value

Base Units 5

Time Units (60

4
Min)

Modifying Units
1
(P3)

Total Units 10

Conversion Factor $22.00

$220.
Total Payment
00

🧩 Anesthesia Modifier Flowchart: Team-Based Care

Was Anesthesiologist Alone?

└─ Yes → Use **AA**
└─ No →
Was CRNA Alone?
└─ Yes → Use **QZ**
└─ No →
Anesthesiologist Directed?
├─ Anesthesiologist: **QK** (2–4 Cases) Or **QY** (1 Case)
└─ CRNA: **QX**

📌 Physical Status Modifier (E.G., -P3) Goes After The Anesthesia Modifier
📌 Qualifying Circumstances (99100–99140) Are Reported On A Separate Line
📝 Team-Based Example

CRNA Performs Anesthesia (Code 00220) Under Anesthesiologist’s Direction (3 Total

Cases); Patient = P2

 Anesthesiologist: 00220-QK-P2
 CRNA: 00220-QX-P2

🧮 Anesthesia Payment Units Flowchart

Step 1: Identify CPT® Code (00100–01999)
Step 2: Find Base Units from ASA Or CMS
Step 3: Divide Time (Minutes ÷ 15) = Time Units
Step 4: Add Modifying Units
➤ Physical Status (P1–P6)
➤ 99100 (Extreme Age) = 1 Unit
➤ 99140 (Emergency) = 2 Units
➤ 99116 (Hypothermia) = 5 Units
➤ 99135 (Hypotension) = 5 Units
Step 5: Add All Units = Total Units
Step 6: Multiply By Conversion Factor = Payment
✅ Memorization Aids
 Code Ranges:

o 00100–01999 = Anesthesia by site

o 01990–01992 = Other procedures

o 99100–99140 = Qualifying circumstances

o 99151–99157 = Moderate sedation

 Team-Based Modifiers Summary:

Modifi
Role
er

Anesthesiologist (solo) AA

CRNA (solo) QZ

Anesthesiologist (directs
QY
1)

Anesthesiologist (directs
QK
2–4)

CRNA (when directed) QX

🧠 Mnemonics to Remember Units

 Base + Time + Modifiers = BTM = "Bottom line" for total units

 "15 Minutes = 1 Unit" → think of a quarter hour as a unit of care

 ✅ CPT® Modifiers

Modifi
Use Case Example
er

Significant E/M On Same Day As 99213 With 17000 (Wart

-25
Procedure Destruction)

-26 Professional Component Only Reading A Chest X-Ray

-51 Multiple Procedures, Same Session Excision Of Two Benign Lesions

-52 Reduced Services Partial Colonoscopy

Two Procedures, Different

-59 Distinct Procedural Service
Sites/Sessions

-76 Repeat Procedure By Same Provider 2 X-Rays Same Day

-77 Repeat By Different Provider 2nd Echo By Another Cardiologist

-80 Assistant Surgeon Surgical Assistant On Hernia Repair

⚙️Modifiers For Anesthesia

Physical Status Modifiers (P1–P6):

Units
Modifi
Description Adde
er
d

P1 Normal Healthy Patient 0

P2 Mild Systemic Disease 0

P3 Severe Systemic Disease 1

Severe Systemic Disease—Life

P4 2
Threat

Moribund, Not Expected To

P5 3
Survive

P6 Brain-Dead Organ Donor 0

Other Modifiers:

Modifi
Meaning
er

AA Anesthesia By Anesthesiologist

Med Direction Of 5+ Concurrent

AD
Procedures

QK Med Direction Of 2–4 Procedures

QX CRNA With Med Direction By Physician

Modifi
Meaning
er

QY One CRNA + One Physician Direction

QZ CRNA Services Without Physician

✅ Post-Op Modifier Decision Tree Summary

Modifi
Situation
er

Planned/Staged Related Return -58

Unplanned Return For

-78
Complication

Unrelated New Procedure -79

E/M Visit Unrelated To Surgery -24

Same Procedure, Same

-76
Provider

Same Procedure, Different

-77
Provider

✅ Z-Code Coding Tips

 Never Use Z01.81x (Pre-Op Clearance) Alone.

 Sequence Chronic Condition First, Then Z-Code.

 Also, Code for Reason for Surgery (E.G., Cholelithiasis, Neoplasm).

🩻 Pre-Op E/M & Anesthesia Clearance Coding

🔹 1. E/M For Pre-Op Visits (Evaluation By PCP Or Specialist)

✅ When to Use:

 Patient Is Evaluated to Assess Fitness for Surgery

 Visit Is Medically Necessary, Not Part of the Global Surgical Package

 Patient Has Chronic Conditions Requiring Clearance (E.G., Hypertension,

Diabetes, COPD)
📘 Key Codes:

 E/M Code (E.G., 99202–99215 For Office Visit Depending on

Complexity)

 Z01.81x – Preprocedural Exam (Based On Body System: Cardio, Resp,

Labs, Other)
  Chronic Condition(S): I10, E11.9, J44.9, Etc.

 Surgical Reason: K80.21, N40.1, Etc.

🧠 Coding Sequence:

 Chronic Condition(S) – Reason For Clearance

 Surgical Diagnosis – Reason For Planned Procedure

 Z01.81x – Type of Pre-Op Exam

 E/M Level – Based on Documentation

📌 Example:

Patient With COPD Is Cleared by PCP For Cataract Surgery.

 J44.9 (COPD)

 H26.9 (Cataract)

 Z01.811 (Respiratory Clearance)

 99214 (Established Patient, Moderate Complexity)

🔹 2. Anesthesia Clearance Documentation

✅ When to Use:

 Anesthesiologist Performs a Separate Pre-Op Eval Outside The OR

 Requires Full Documentation Of HPI, ROS, Exam, MDM

 Can Bill Separately from Anesthesia Services If Medically

Necessary

 Medically Necessary Clearance Not Part of Global

Surgical Package

 Patient Has Chronic Conditions (E.G., HTN, DM, COPD)

 Evaluation For Surgical Fitness

E/M Code:

o Office: 99202–99215

o Inpatient: 99221–99223 (Initial), 99231–99233 (Subsequent)

 Z01.818 – Other Preprocedural Exam

o Surgical Condition (E.G., K57.30 For Diverticulosis)

o Chronic Conditions (E.G., I10)

o E/M Code: 99202–99215 (Office Visit)

o Z01.81x – Preprocedural Exam:

 Z01.810 – Cardiovascular

 Z01.811 – Respiratory
  Z01.812 – Lab

 Z01.818 – Other
🧠 Coding Sequence:

 Chronic Condition(S) – Reason For Clearance

 Surgical Condition – Reason for Planned Procedure

o Z01.81x – Type of Pre-Op Clearance

o E/M Code – Based On Documentation

🧠 Key Points:

 Must Be Documented and Separately Identifiable

o Modifier 25 May Be Required If on The Same Day as Anesthesia Services

o Time-Based E/M May Apply If Prolonged Discussion Is Needed

🛑 Don’t Forget:

 Z01.81x Codes Are Not First-Listed Unless It's a Routine Pre-Op Visit

 Global Period Rules Apply — Don’t Bill E/M For Routine Pre-Op by Surgeon

 Consultations (99242–99245, 99252–99255) May Apply If Requested By Another

Provider And Documentation Supports It

🩺 Complete Guide to Global Surgical Periods (Gsp)

 🔍 what is a global surgical period?

 A global surgical period (Gsp) refers to the time frame during which all necessary
services provided by a surgeon related to a surgical procedure are included in a single,
bundled payment. These services are not billed separately and are considered part of the
global surgical package. The gsp is defined and recognized by Medicare and most
private payers.

🕒 Duration of global surgical periods

 Procedure  Global  Medicare global

 Explanation
type period indicator

 Minor  0 or 10  000 (0-day), 010  Includes all pre-op, intra-op, and post-op
surgery days (10-day) care within 0 or 10 days.

 Major  Includes surgery and all related follow-up

 90 days  090
surgery care for 90 days.

 Note: the global period starts the day after surgery, not on the day of surgery.


⚙️What’s Included in the global surgical package?

 All care directly related to the surgery that occurs before, during, And After the
Operation Is Included in the Global Fee.

 Pre-Operative Care
 Initial Evaluation Related to the Condition

 Decision For Surgery (Often Billed Separately If Not On Same Day)

 Pre-Surgical Testing (Bloodwork, Imaging, Etc.)

Intra-Operative Care

 The Surgical Procedure

 Anesthesia Services (If Provided By the Surgeon)

 Surgical Supplies and Tools

♻️Post-Operative Care

 Follow-Up Office Visits

 Wound Care, Suture/Staple Removal

 Management Of Routine Surgical Recovery

 Treatment Of Complications Related to The Procedure (Non-Return To OR)

📝 Services Excluded from The Global Surgical Package

 The Following Can Be Billed Separately If Properly Documented and Supported:

 ❌ Unrelated Services
 Conditions Not Associated with The Original Surgery (E.G., Flu, Unrelated Joint Pain)

 ❌ New Procedures
 A Different, Unrelated Procedure During the Global Period
→ Use Modifier -79

 ❌ Return to Operating Room for Complications

 Unplanned Return to OR Due To Complications Of Original Procedure
→ Use Modifier -78

 ❌ Unrelated E/M Services

 Evaluation And Management Services Not Related to the Surgery (E.G., Physical
Exams, Chronic Condition Management)
→ Use Modifier -24

 ❌ Therapies
 Physical Therapy, Occupational Therapy, And Other Rehabilitation Services May Be
Billed Separately (Check Payer Rules)


🔄 Modifiers Impacting the Global Surgical Package

 Modifi
 Description  Purpose
er

 Unrelated E/M
 -24 Service During  E/M For Different Issue (E.G., Different Body System)
Post-Op Period

 Postoperative
 -55 Management  When A Different Provider Handles The Follow-Up Care
Only

 Unplanned
Return To OR  Complication Management in The OR; No New Global
 -78
For Related Period
Complications

 Unrelated
Procedure
 -79  New Condition/Procedure; Starts New Global Period
During Global
Period

 💡 Tip: Always Document Medical Necessity and Clear Differentiation In Diagnosis

Codes When Using Modifiers -24 Or -79.

 🚨 Important Considerations
 Day 0 Vs. Day 1: The Day of The Procedure Is Not Part of the Post-Op Period — The
Global Period Begins The Next Day.

 Cumulative Services: All Care Related to the Original Surgery Is Considered Part of
the Single Global Fee — You Cannot Bill Each Follow-Up Separately.
Clear Documentation: Modifier Use Must Be Backed By Distinct Documentation, Ideally
With Different ICD-10-CM Codes To Show Unrelatedness

 CPT® Coding (Outpatient & Professional Services)

 HCPCS Level II Coding
 Modifiers – CPT & HCPCS
 Diagnosis-Procedure Linkage

Section 3: Medical Necessity and Documentation

 Importance of Clinical Documentation
 Linking Diagnosis to Services
 Ncds and lcds (National and Local Coverage Determinations)
 Common Medical Necessity Denials and Resolutions
 Signature and Authentication Requirements
 Section 4: Billing Process Overview
 Patient Registration and Insurance Verification
 Charge Capture and Coding
 Claim Form Types (CMS-1500, UB-04)
 Claim Submission: Clearinghouses and Direct Entry
 Claims Adjudication Process
 Coordination of Benefits (COB)

Section 5:

Sample E/M Leveling Decision Tree

The following is a simplified E/M leveling decision tree based on 2021 guidelines for
Office/Outpatient visits:

1. Determine if the visit is new or established.

2. Choose between Time or Medical Decision Making (MDM) as the basis for leveling.
3. If using MDM, evaluate the number and complexity of problems addressed,
amount/complexity of data reviewed, and risk of complications.
4. Match the criteria to the correct E/M level (e.g., 99202–99205 for new, 99212–99215 for
established).

NOTE: Detailed documentation and reference to CMS or CPT® guidelines are critical for
accuracy.

Denial Management Workflow

A standard denial management workflow typically includes the following steps:

1. **Denial Identification**
- Receive and categorize the denial (e.g., coding error, eligibility, lack of documentation).

2. **Root Cause Analysis**

- Determine why the denial occurred (e.g., incorrect modifier, medical necessity issue).

3. **Appeal/Correction**
- Submit corrected claims or appeal with supporting documentation.

4. **Follow-up**
- Monitor for payer response and payment.

5. **Trend Analysis and Prevention**

- Log denials and outcomes in a system to identify patterns and initiate preventative actions.

This workflow supports faster recovery and fewer recurring errors.