Being a Medical Information Coder

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Edition: 3rd
Format: Paperback
Pub. Date: 2003-05-15
Publisher(s): Pearson
List Price: $94.20

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Summary

This book provides an introduction to ICD-9-CM coding that is easy to read and understand but covers basic coding principles comprehensively. With its focus on diagnosis, symptoms, and procedures related to these systems, coding principles are introduced and reinforced throughout.This book provides in-depth coverage of ICD-9-CM coding for medical information professionals, and discusses procedure codes, anatomy, physiology, pathophysiology, medical record content, and computer use.A valuable reference tool for Registered Health Information Technologists (RHITs) and Credentialed Coding Specialists (CCSs).

Author Biography

Laurie Dodson, RHIA, MPH, received her graduate degree from UCLA's School of Public Health with an emphasis on Health Information Systems. For the past 23 years she has been an instructor in Cypress College's Health Information Technology program in California, where she has taught classes in entry-level coding with ICD9-CM. She therefore recognizes many of the problem areas where students have trouble with coding.

Table of Contents

Foreword xiii
Preface xiv
Introduction to the Medical Information Coder
1(12)
Vocabulary
1(1)
Objectives
1(1)
Uniform Hospital Discharge Data Set
2(1)
Disease and Procedures Indexes
3(1)
Purpose of Coding
3(1)
History of Nomenclature and Classification Systems
4(1)
ICD-9
4(1)
ICD-9-CM
4(1)
Educational Requirements
5(1)
HCPCS/CPT-4 Coding
5(1)
Registered Health Information Technician
6(1)
Job Description
7(1)
Reference Materials
7(1)
Continuing Education
7(4)
Summary
11(1)
Learning Activities
11(2)
Introduction to ICD-9-CM Coding
13(22)
Vocabulary
13(1)
Objectives
13(1)
Medical Record as a Source Document
14(9)
Index
23(2)
Tabular List
25(2)
Coding Conventions
27(6)
Basic Coding Rules
33(1)
Summary
34(1)
Learning Activities
34(1)
Procedure Codes
35(11)
Vocabulary
35(1)
Objectives
35(1)
Excision
36(1)
Omit Code
37(1)
Open vs. Closed Biopsy
38(1)
Open vs. Closed Reduction
39(2)
Multiple Codes
41(1)
Canceled Surgery
41(1)
Surgery Not Completed
42(1)
Summary
43(1)
Learning Objectives
43(3)
Infectious and Parasitic Disease
46(10)
Vocabulary
46(1)
Objectives
46(1)
Intestinal Infections
46(1)
Other Food Poisoning
47(1)
Gastroenteritis, Colitis, and Enteritis
48(1)
Tuberculosis
49(1)
Opportunistic Mycosis
49(1)
Zoonotic Bacterial Disease
50(1)
Multiple Coding
50(1)
Bacteria and Viruses
51(1)
Human Immunodeficiency Virus
51(2)
Late Effects
53(1)
Drug-Resistant Infections
53(1)
Summary
53(1)
Learning Activities
53(3)
Neoplasms
56(16)
Vocabulary
56(1)
Objectives
56(1)
Primary Site
57(1)
Secondary Sites
57(1)
Nonsolid Tumors
58(1)
In Situ
58(1)
Benign Neoplasm
59(1)
Uncertain Behavior
59(1)
Unspecified Behavior
59(1)
Overrides
59(1)
Morphology
60(2)
History of Neoplasm
62(1)
Recurrent Primary
63(1)
Multiple Primaries
63(1)
Unknown Primary
63(2)
Functional Activity
65(1)
Malignant Neoplasm of Lymphatic and Hematopoietic Tissue
65(1)
Admission for Chemotherapy or Radiotherapy
66(1)
Aftercare vs. Follow-Up
67(2)
Summary
69(1)
Learning Activities
69(3)
Endocrine, Nutritional, and Metabolic Disease and Immunity Disorders
72(12)
Vocabulary
72(1)
Objectives
72(1)
Neonatal Endocrine Disorders
72(1)
Goiter
73(1)
Use of E-Codes
73(1)
Congenital vs. Acquired
74(1)
Acute Thyroiditis
75(2)
Diabetes Mellitus
77(2)
Gestational Diabetes Mellitus
79(1)
Diabetes Complicating Pregnancy
80(1)
Hyperglycemia
80(1)
Insulin Coma
80(1)
Steroid-Induced Diabetes
80(1)
Summary
81(1)
Learning Activities
81(3)
Blood and Blood-Forming Organs
84(5)
Vocabulary
84(1)
Objectives
84(1)
Anemia
84(3)
Purpura
87(1)
Summary
87(1)
Learning Activities
87(2)
Mental Disorders
89(13)
Vocabulary
89(1)
Objectives
89(1)
DSM
89(2)
Psychoses
91(1)
Organic Brain Syndrome
91(1)
Alcoholic Psychoses
91(1)
Drug Psychoses
92(1)
Override
92(1)
Schizophrenic Disorders
93(1)
Manic-Depressive Disorders
93(2)
Neuroses
95(1)
Personality Disorders
95(1)
Alcohol and Drug Dependence
96(2)
Psychogenic Origins
98(1)
Circumstances Affecting Mental Health
99(1)
Mental Retardation
100(1)
Summary
100(1)
Learning Activities
100(2)
Diseases of the Nervous System and Sense Organs
102(7)
Vocabulary
102(1)
Objectives
102(1)
Meningitis
102(1)
Encephalitis
103(1)
Late Effects
104(1)
Epilepsy
105(1)
Headache
105(1)
Sense Organs
105(1)
Blindness
106(1)
Hearing Loss
107(1)
Summary
107(1)
Learning Activities
107(2)
Diseases of the Circulatory System
109(21)
Vocabulary
109(1)
Objectives
109(1)
Rheumatic Fever
110(1)
Hypertension
111(3)
Elevated vs. High Blood Pressure
114(1)
Ischemic Heart Disease
114(2)
Angina
116(2)
Chest Pain
118(1)
Cardiac Failure
118(1)
Coronary Atherosclerosis
118(2)
Conduction Disorders
120(1)
Functional Disturbances Following Cardiac Surgery
120(1)
Cerebrovascular Disease
120(2)
Cerebrovascular Accident
122(2)
Late Effects
124(1)
Heart Catheterization
124(1)
Angiocardiography
125(1)
His Bundle Study
125(1)
Circulatory Monitoring
125(1)
Cardiopulmonary Bypass
125(1)
Coronary Artery Bypass
125(1)
Complications of Coronary Artery Bypass
125(1)
Pacemakers
126(2)
Pacemaker Syndrome
128(1)
Status Codes
128(1)
Summary
128(1)
Learning Activities
128(2)
Diseases of the Respiratory System
130(8)
Vocabulary
130(1)
Objectives
130(1)
Acute vs. Chronic
130(1)
Acute Sinusitis
131(1)
Pneumonia
132(1)
Asthma
133(1)
Chronic Obstructive Pulmonary Disease
133(1)
Pneumoconioses
134(1)
Respiratory Conditions Due to Chemicals and Vapors
135(1)
Respiratory Failure
135(1)
Summary
136(1)
Learning Activities
136(2)
Diseases of the Digestive System
138(8)
Vocabulary
138(1)
Objectives
138(1)
Ulcers
138(1)
Paralytic Ileus
139(1)
Other Postgastric Surgery Complications
140(1)
Hernia
140(1)
Repair of Inguinal Hernia
141(1)
Diverticulosis vs. Diverticulitis
141(1)
Cholecystotomy
141(2)
Laparatomy
143(1)
Endoscopic Retrograde Cholangiopancreatography
144(1)
Summary
144(1)
Learning Activities
144(2)
Diseases of the Genitourinary System
146(8)
Vocabulary
146(1)
Objectives
146(1)
Ureter vs. Urethra
146(1)
Urosepsis
147(1)
Endometriosis
147(1)
Fistula
148(1)
Diagnostic Studies
148(2)
Chronic Renal Failure
150(1)
Renal Dialysis
150(1)
Urinary Tract Infection
151(1)
Summary
151(1)
Learning Activities
151(3)
Complications of Pregnancy, Childbirth, and the Puerperium
154(21)
Vocabulary
154(1)
Objectives
154(1)
Ectopic and Molar Pregnancies
154(1)
Abortive Outcome
154(1)
Other Complications Affecting the Abortion
154(2)
Complications of Previous Abortion
156(1)
Complications of Pregnancy
156(1)
Fifth Digits
156(2)
Normal Delivery
158(1)
Multiple Gestation
159(1)
Malpresentation
159(2)
Known or Suspected Fetal Abnormalities
161(1)
Rh Factor Incompatibility
161(1)
Intrauterine Death
161(1)
Polyhydramnios
162(1)
Premature Rupture of Membranes
162(1)
Grand Multiparity
162(1)
Elderly Primagravida
163(1)
Uterine Inertia
163(1)
Umbilical Cord Complications
163(1)
Perineal Laceration
164(1)
Postpartum Hemorrhage
164(1)
Retained Placenta
165(1)
Forceps Extraction and Cesarean Delivery
166(1)
Outcome of Delivery
166(1)
Sterilization
167(1)
Infections of the Breast
168(1)
Supervision of Normal Pregnancy
169(1)
Supervision of High-Risk Pregnancy
169(1)
Pregnant State
170(1)
Postpartum Care
170(1)
Summary
171(1)
Learning Activities
171(4)
Certain Conditions Originating in the Perinatal Period
175(10)
Vocabulary
175(1)
Objectives
175(1)
V30-V39
175(1)
Premature Birth
176(1)
Postterm Birth
177(1)
Maternal Conditions Affecting the Fetus or Newborn
178(1)
Birth Injuries
178(1)
Fetal Distress and Fetal Death
178(1)
Congenital vs. Acquired
179(1)
Maternal Infections Affecting the Fetus
180(1)
Hemolytic Disorders
180
Fetal Death
178(4)
Summary
182(1)
Learning Activities
182(3)
Congenital Anomalies
185(4)
Vocabulary
185(1)
Objectives
185(1)
Cleft Palate and Cleft Lip
185(2)
Summary
187(1)
Learning Activities
187(2)
Diseases of the Skin and Subcutaneous Tissue
189(4)
Vocabulary
189(1)
Objectives
189(1)
Dermatitis
189(1)
Keloid vs. Cicatrix
190(1)
Excision of Lesions
190(1)
Ulcers of the Skin
190(1)
Summary
191(1)
Learning Activities
191(2)
Diseases of the Musculoskeletal System and Connective Tissues
193(10)
Vocabulary
193(1)
Objectives
193(1)
Arthropathies
194(1)
Arthropathy Associated with Infections
195(1)
Traumatic Arthropathy
196(1)
Internal Derangement of the Knee
196(1)
Dorsopathies
196(1)
Spondylosis
196(1)
Enthesopathies
197(1)
Pathological Fracture
197(1)
Malunion/Nonunion
197(1)
Valgus vs. Varus
198(1)
Curvature of the Spine
198(1)
Nonallopathic Lesions
199(1)
Summary
200(1)
Learning Activities
200(3)
Symptoms, Signs, and Ill-Defined Conditions
203(6)
Vocabulary
203(1)
Objectives
203(1)
Coma
204(1)
Hallucinations
204(1)
Co-morbidity and Complications
205(1)
Obvious Symptoms
205(1)
Sleep Disturbances
205(1)
Gangrene
206(1)
Nonspecific Findings
206(1)
Ill-Defined Conditions
206(1)
Summary
207(1)
Learning Activities
207(2)
Injury and Poisoning
209(21)
Vocabulary
209(1)
Objectives
209(1)
Multiple Coding
210(1)
Sequencing
210(1)
Late Effects
211(1)
Fractures
211(1)
Skull Fracture
211(1)
Fracture of Vertebra
211(1)
Fracture of Radius and Ulna
212(1)
Open vs. Closed Reduction
212(1)
Dislocation
213(3)
Fracture-Dislocation
216(1)
Sprains and Strains
216(1)
Open Wounds
216(1)
Superficial Injury
216(3)
Contusions
219(1)
Burns
219(1)
Extent of Burn
220(2)
Certain Traumatic Complications
222(1)
Poisoning by Drugs or Medicinal and Biological Substances
223(1)
Effects of Environmental Influences
224(1)
Adverse Effects
224(1)
Complications of Surgical and Medical Care
225(1)
Complications vs. Aftercare vs. Follow-Up
225(1)
Summary
225(1)
Learning Activities
226(4)
External Causes of Injury and Poisoning
230(12)
Vocabulary
230(1)
Objectives
230(1)
Railway Accidents
231(1)
Motor Vehicle Traffic Accidents
231(3)
Place of Occurrence
234(1)
Poisonings and Adverse Effects
235(1)
Misadventures during Surgical and Medical Care
236(1)
Abnormal Reactions to Surgical or Medical Care
237(3)
Other Accidents
240(1)
Late Effects
240(1)
Summary
240(1)
Learning Activities
240(2)
V-Codes
242(8)
Vocabulary
242(1)
Objectives
242(1)
Potential Health Hazards
243(1)
History of Disease
243(1)
Circumstances Related to Reproduction and Development
244(1)
Persons with a Condition Influencing Health Status
244(1)
Aftercare
244(1)
Rehabilitation
245(1)
Procedures Not Carried Out
245(1)
Follow-Up Examination
245(3)
Observation
248(1)
Special Screening
248(1)
Summary
248(1)
Learning Activities
248(2)
Diagnosis Related Groups
250(7)
Vocabulary
250(1)
Objectives
250(1)
MDCs
251(1)
DRGs
252(1)
DRG Coordinator
253(1)
Concurrent Coding
254(1)
Computerized Systems
255(1)
PROs
255(1)
Updates
255(1)
Summary
255(1)
Learning Activities
256(1)
Ambulatory Coding
257(4)
Vocabulary
257(1)
Objectives
257(1)
Probables
257(1)
Multiple Coding
258(1)
Chronic Diseases
258(1)
Ancillary Services
258(1)
Services Rendered
258(1)
Ambulatory Surgery
258(1)
Aftercare
259(1)
Pregnant Patients
259(1)
Summary
259(1)
Learning Activities
259(2)
Coding Compliance
261(3)
Vocabulary
261(1)
Objectives
261(1)
Health Insurance Portability and Accountability Act
261(1)
Office of Inspector General
262(1)
Compliance Managers
262(1)
Internal Monitoring
262(1)
Physician Documentation
262(1)
Outside Contractors
263(1)
Summary
263(1)
Learning Activities
263(1)
Appendix: Coding Specialist Certification Program 264(2)
References 266(1)
Index 267

Excerpts

While many American industries seem to be in decline, the health care industry is growing. With an aging population needing more attention and with new technologies revolutionizing the delivery of health care, the industry is "healthy."Information is an especially necessary commodity for success. Top managers need statistics to aid in decision-making activities. To determine the effectiveness of treatments and diagnostic tools, physicians need information. Government agencies on both the federal and state levels use comparative data to monitor quality of care, and insurance companies need information in order to evaluate claims and plan for the future. The health information specialist is trained and ready to meet these ever-growing demands.Coders have long played a role in making it possible to store and retrieve health information. With the federal government's prospective payment system, which relies on complete, accurate coding using the ICD-9-CM coding system, the role has taken on added importance.Previously, reimbursement depended on length of stay and diagnostic procedures performed. Now, medical information coders are required to review medical records looking for ways to optimize potential reimbursement. Their skills are of utmost importance, and job opportunities abound. Each day offers new ways in which health information specialists can demonstrate their value and impact on the successful delivery of health care.This book is part of a series developed by Prentice Hall to introduce the student to the ever-growing opportunities evident in the health information departments throughout the health care industry. Other books in the series address hospital admitting, insurance billing (which includes CPT coding), and medical transcription.Chapter 1 introduces the student to the medical information coder and to the medical record as a source document for gathering information. Chapter 2 introduces the student to ICD-9-CM, the international coding system modified for use in the United States and used to record both diagnoses and procedures in the inpatient setting.Chapters 3 to 22 take the student step by step through the coding system, pointing out guidelines and problem areas and demonstrating key concepts. At the conclusion of each chapter are exercises that provide opportunities for the student to code health information using newfound skills.Chapter 23 gives the student an overview of the prospective payment system endorsed by the federal government in reimbursement efforts for Medicare patients. Any medical information coder must expand his or her knowledge of this system, because the financial wellbeing of facilities partially depends on the coding skills of these important people.Chapter 24 portrays differences between coding in the inpatient setting and the outpatient or ambulatory setting. While many of the codes are the same, some coding rules differ and must be recognized in order to provide accurate and complete codes.Chapter 25 addresses the need for coding compliance managers. The 1996 Health Insurance Portability and Accountability Act (HIPPA) gave added importance to coding accuracy, therefore ongoing monitoring systems must be in place to screen codes for fraud and abuse and look at high risk areas such as alcohol and drug abuse, HIV, and cancer. Compliance managers must coordinate the activities of physicians, coders, and other health care providers to make sure that health information is accurate, confidential, and documented.Coding is an exciting career opportunity for enthusiastic people with a keen interest in health information. I hope that this book will start many on their way to new horizons in coding. Laurie Dodson

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