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iii



2014

THE NEXT STEP
ADVANCED MEDICAL CODING
and AUDITING

Carol J. Buck
MS, CPC, CPC-H, CCS-P
Former Program Director
Medical Secretary Programs
Northwest Technical College
East Grand Forks, Minnesota


3251 Riverport Lane
St. Louis, Missouri 63043
THE NEXT STEP: ADVANCED MEDICAL CODING
AND AUDITING, 2014 EDITION

ISBN: 978-1-4557-5897-5

Copyright © 2014, 2013, 2012, 2011, 2010, 2009, 2008, 2006, 2004 by Saunders, an imprint of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations
such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
NOTE: Current Procedural Terminology, 2014, was used in updating this text.
Current Procedural Terminology (CPT) is copyright 2013 American Medical Association. All Rights Reserved.
No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no
liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties
for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Buck, Carol J., author
  The next step : advanced medical coding and auditing / Carol J. Buck.—2014
   p. ; cm.
  Includes index.

  ISBN 978-1-4557-5897-5 (pbk. : alk. paper)
  I. Title.
  [DNLM: 1. Clinical Coding—Problems and Exercises. W 18.2]
R728.8 616.001’2—dc23
Content Strategy Director: Jeanne R. Olson
Associate Content Development Specialist: Helen O’Neal
Publishing Services Manager: Pat Joiner
Project Manager: Lisa A. P. Bushey
Senior Designer: Amy Buxton
Printed in Canada
Last digit is the print number:  9  8  7  6  5  4  3  2  1

2013020953


To all the students, whose abilities to surmount tremendous obstacles to
achieve their goals have been a source of unending inspiration.
To the teachers, who give of their talent, time, and knowledge to help
the students who enter their classrooms, may this work make your load
just a little lighter as we travel the same road, toward the same goal.
To my husband, Dennis, for understanding the mission, supporting the
journey, and keeping the faith.

Carol J. Buck


This page intentionally left blank


Collaborators and Reviewers

Senior Technical Collaborator

Senior Coding Specialist

Sheri Poe Bernard, CCS-P, CPC, CPC-H, CPC-I
Coding Education Specialist
Salt Lake City, Utah

Jacqueline Klitz Grass, MA, CPC
Coding and Reimbursement Specialist
Grand Forks, North Dakota

Query Manager

Editorial Reviewer Board

Patricia Cordy Henricksen, MS, CHCA, CPC-I, CPC,
CCP-P, ACS-PM
Auditing and Coding Educator
Soterion Medical Services
Lexington, Kentucky

Judy B. Breuker, CPC, CPMA, CCS-P, CHCA, PCS,
CEMC, CHC, CHAP,
AHIMA-Approved ICD-10-CM/PCS Trainer
President of Medical Education Services, LLC
Hudsonville, Michigan

Senior Collaborator and ICD-10-CM
Consultant

Donna L. Fuchs, CPC, RMA
Medical Instructor
Medical Coding/Billing
Metro Business College
Arnold, Missouri

Nancy Maguire, ACS, CRT, PCS, FCS, HCS-D, APC, AFC
Physician Consultant for Auditing and Education
Winchester, Virginia

Senior ICD-10-CM and ICD-9-CM
Coding Specialist

Karen Sue Braddock, BA, MA, CPC-A, CPC-H-A
Coder and Curriculum Development Specialist
AAPC, AHIMA
Seattle, Washington

Karla R. Lovaasen, RHIA, CCS, CCS-P*
Coding and Consulting Services
Abingdon, Maryland
*Coauthor of ICD-9-CM Coding: Theory and Practice with
ICD-10, 2013/2014 Edition, and ICD-10-CM/PCS Coding:
Theory and Practice, 2013 Edition, St. Louis, 2013, Saunders.

xi


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Contents
REFACE, xv
P
ACKNOWLEDGMENTS, xxv
LIST OF PHYSICIANS, xxvii
1 Evaluation and Management Services, 1
2 Medicine, 77
3 Radiology, 105
4 Pathology and Laboratory, 142
5 Integumentary System, 180
6 Cardiovascular System, 221
7 Digestive System, Hemic/Lymphatic System, and Mediastinum/Diaphragm, 262
8 Musculoskeletal System, 313
9 Respiratory System, 345
10 Urinary, Male Genital, and Endocrine Systems, 389
11 Female Genital System and Maternity Care/Delivery, 417
12 Nervous System, 449
13 Eye and Auditory Systems, 476
14 Anesthesia, 493
FIGURE CREDITS, 522
APPENDICES
A E/M Audit Form, 523
B CMS AB-01-144, 525
C Resources, 528
ICD-10-CM Official Guidelines for Coding and Reporting


ICD-9-CM Official Guidelines for Coding and Reporting

1995 Guidelines for E/M Services

1997 Documentation Guidelines for Evaluation and Management Services

CPT Updates

ICD-10-CM Updates

ICD-9-CM Updates

HCPCS Updates

Study Tips

WebLinks
D Abbreviations, 529
E Answers to Every Other Case, 534
GLOSSARY, 561
INDEX, 565

xiii


This page intentionally left blank


Preface

Patricia Cordy Henricksen, MS, CHCA, CPC-I,

CPC, CCP-P, ACS-PM

Auditing and Coding Educator
Soterion Medical Services
Lexington, Kentucky

Types of Codes
This text presents cases that are to be coded with service codes (CPT and HCPCS) and diagnosis codes (ICD-10-CM and
ICD-9-CM) in the outpatient settings of the clinic and outpatient departments of the hospital for the physician (professional).
Answer lines are provided for both the ICD-10-CM and ICD-9-CM codes, along with rationales within the textbook categorized
in this same way. In this way, you can choose to code either ICD-10-CM codes or ICD-9-CM codes or both. The transition
from ICD-9 to ICD-10 is expected to be finalized on October 1, 2014. On or after that date, ICD-9-CM codes will no longer be
accepted by most payers and the ICD-9 coding system will no longer be updated.
Appendix C of this text displays the website to reference the 1995 and 1997 Documentation Guidelines for Evaluation and
Management Services. Each medical facility chooses one of the documentation guidelines and submits all Medicare and Medicaid
E/M charges using that specific set of guidelines. This text has been developed using the 1995 guidelines, as that tends to be the
more popular version. Even though the private third-party payers (not Medicare, Medicaid, or any other government program)
may not require adherence to a specific set of E/M documentation guidelines, the facility-chosen guidelines are usually applied
to all E/M services.
Unlike the inpatient coder, who has all the documentation from a hospital stay available when assigning diagnoses codes,
the outpatient coder reports diagnoses based on the information present in the one report being coded. In this text, a case may
contain numerous reports that chronicle the patient’s care. When coding each of the reports in the case, the coder is to consider
only the diagnoses information present in that report, because this is the way the reports are coded in outpatient settings. For
example, a physician admits a patient to the hospital for possible pneumonia with chief complaint of shortness of breath and
wheezing. The coder reporting the physician’s admit service would report the symptoms of shortness of breath and wheezing,
even though on a subsequent report within that case the physician does diagnose the patient’s condition as pneumonia. One
exception to this rule would be when coding an operative report in which a specimen was sent to the pathology department for
analysis. The pathologist’s diagnosis would be used as the diagnosis when coding the operative report, because the findings are
usually more current and definitive than the diagnosis stated by the surgeon.
Clarification regarding the reporting guidelines for diagnostic tests, such as pathology reports, is located in AB-01-144.

The Centers for Medicare and Medicaid, Program Memorandum (PM), Transmittal AB-01-144 is displayed in Appendix B
of the text and outlines current coding guidelines for reporting the diagnosis for diagnostic tests. The PM provides direction
on coding diagnostic tests and coordinates with the Official Guidelines for Coding and Reporting. Although there is no
specific memorandum for ICD-10-CM, the content of the ICD-9-CM memorandum is still applicable. An excerpt from the
PM is as follows:

xv


xvi

Preface

A. Determining the Appropriate Primary Diagnosis Code for Diagnostic Tests
Ordered due to Signs and/or Symptoms
1. If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should
code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if
they are not fully explained or related to the confirmed diagnosis.
Example 1: A surgical specimen is sent to a pathologist with a diagnosis of “mole.” The pathologist personally reviews the slides
made from the specimen and makes a diagnosis of “malignant melanoma.” The pathologist should report a diagnosis
of “malignant melanoma” as the primary diagnosis.
Example 2: A patient is referred to a radiologist for an abdominal CT scan with a diagnosis of abdominal pain. The CT scan
reveals the presence of an abscess. The radiologist should report a diagnosis of “intra-abdominal abscess.”
The PM is an important document to read before beginning to use this text, because it outlines the guidelines used when
this text was developed. The coder is introduced to this document in Chapter 1 of the text under the heading Diagnosis Coding.
This document has foundational information that must be carefully read and thoroughly understood by the coder prior to
assigning diagnosis codes. The links to the Official Guidelines for Coding and Reporting are also displayed in Appendix C.
A List of Physicians is located on pages xxvii–xxviii of the text and contains the names of the physicians that provide
services to the patients in this text. The list is displayed in alphabetic order by physician last name and by specialty. There are two
physicians who are employed by the hospital (Dr. Hart and Dr. Sutton), and the remaining physicians are employed at the local

clinic. The coder will be assigning codes for all the physicians.
Select abbreviations and acronyms used in the cases in each chapter are displayed at the beginning of each chapter.
Appendix D contains a compilation of these abbreviations and acronyms.

Content
The following are the chapters of this text:
1. Evaluation and Management Services
2. Medicine
3. Radiology
4. Pathology and Laboratory
5. Integumentary System
6. Cardiovascular System
7. Digestive System, Hemic/Lymphatic System, and Mediastinum/Diaphragm
8. Musculoskeletal System
9. Respiratory System
10. Urinary, Male Genital, and Endocrine Systems
11. Female Genital System and Maternity Care/Delivery
12. Nervous System
13. Eye and Auditory Systems
14. Anesthesia

From the Trenches
“Certified coders are in high demand in many areas, not only as coders for
physician offices, but for claims review by insurance companies, contract
auditing, outsource billing, and educators.”
PATRICIA


Preface

xvii

The number of cases in each chapter was determined by the complexity of coding and the most common services in the
specialty. For example, Chapter 6, Cardiovascular System, is quite lengthy, as this is a very complex area to code and many of the
basic cardiovascular services such as ECG and cardiac event monitoring, are commonly provided in most outpatient settings.
There are many coding challenges in cardiology, such as coronary artery bypass graft, and only through repeated cases can the
coder gain understanding and then confidence in his/her cardiology coding skill.

Case Numbering System
The cases are numbered by chapter, case, and report. For example, in 7-15A, the “7” indicates that the case appears within
Chapter 7. The “15” indicates that the case is the 15th case in Chapter 7. The “A” indicates that the report is the first report
in the case. Subsequent reports within 7-15 are identified by B, C, etc.
Report within case
7-15A
Chapter number
Case number

Tests are identified by a “T” preceding the case. For example, T7-1A indicates that the test (T) is from Chapter 7, is the first
case (1), and is the first report (A) in the case. The web cases are numbered in the same way, but with a “W” preceding the case.
For example, W7-1A indicates that this is a web case from Chapter 7, is the first case (1), and is the first report (A) in the case.
Each chapter has an outline that lists all the cases and reports at the beginning of the chapter, as illustrated in the following:

Evaluation and Management Services

CASE 6-8

CASE 6-1

6-8A
Echo Doppler Report

CASE 6-9

6-1A

Cardiothoracic Surgery Consultation

Cardiac Artery Bypass Grafts
CASE 6-2
6-2A

Coronary Artery Bypass

Pacemaker
CASE 6-3
6-3A
Cardiology Follow-Up Note
CASE 6-7
6-7A
6-7B
6-7C
6-7D
6-7E

Cardiology Consultation
Hospital Service
Radiography Report, Chest
Cardiothoracic Surgical Consultation
Radiography Report, Chest

6-9A

Cardiology Consultation
CASE 6-12
6-12C
6-12D
6-12E

Radiology Report, Chest
C ardiac Catheterization Report
Radiology Report, GI

Miscellaneous Reports
CASE 6-13
6-13A Cardioversion
CASE 6-14
6-14A

Transesophageal Echocardiogram Report


xviii

Preface

In Chapter 1, Evaluation and Management, the coder is introduced to the following audit form:

HISTORY ELEMENTS
HISTORY OF PRESENT ILLNESS (HPI)

Documented

1.
2.
3.
4.
5.
6.
7.
8.

Location (site on body)
Quality (characteristic: throbbing, sharp)
Severity (1/10 or how intense)
Duration* (how long for problem or episode)
Timing (when it occurs)
Context (under what circumstances does it occur)
Modifying factors (what makes it better or worse)
Associated signs and symptoms (what else is happening
when it occurs)
*Duration not in CPT as HPI Element

•
•
•
•
•
•
•
•

TOTAL

LEVEL

REVIEW OF SYSTEMS (ROS)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Documented

Brief 1-3
None
None

1.
2.
3.
4.
5.
6.

7.

TOTAL
LEVEL

Documented

2
Expanded Problem
Focused

3
Detailed

Brief 1-3
Problem Pertinent 1
None

TOTAL
LEVEL

Extended 4+
Extended 2-9
Pertinent 1

1.
2.
3.
4.
5.

6.
7.
8.
9.
10.
11.

NUMBER

1
Problem
Focused

Limited to
affected BA/OS

4
Comprehensive
# of OS or BA

1

2
Expanded Problem
Focused

Limited to affected
BA/OS & other
related OS(s)
2-7 limited

1.
2.
3.
4.

Documented

Minimal
Limited
Multiple
Extensive

AMOUNT AND/OR COMPLEXITY OF DATA TO REVIEW
1.
2.
3.
4.

Documented

Minimal/None
Limited
Moderate
Extensive

RISK OF COMPLICATION OR DEATH IF NOT TREATED
1.
2.
3.

4.

LEVEL

LEVEL

Documented

Minimal
Low
Moderate
High

MDM*
Number of DX or management
options
Amount and/or complexity of data
Risks

1
Straightforward

2
Low

LEVEL

3
Moderate

4
High

History:

Minimal

Limited

Multiple

Extensive

Examination:

Minimal/None
Minimal

Limited
Low

Moderate
Moderate

Extensive
High

MDM:

MDM LEVEL

*To qualify for a given type of MDM complexity, 2 of 3 elements in the table must be
met or exceeded.

NUMBER
TOTAL BA/OS

Documented

3
Detailed

4
Comprehensive

Extended of affected
BA(s) & other
related OS(s)
2-7 extended

General multi-system
(OSs only)

EXAMINATION LEVEL

HISTORY LEVEL

MDM ELEMENTS
# OF DIAGNOSIS/MANAGEMENT OPTIONS

Documented

Ophthalmologic (eyes)
Otolaryngologic (ears, nose, mouth, throat)
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin)
Neurologic
Psychiatric
Hematologic/Lymphatic/Immunologic

Exam Level

Extended 4+
Complete 10+
Complete 2-3

NUMBER

Head (including face)
Neck
Chest (including breasts and axillae)
Abdomen
Genitalia, groin, buttocks
Back (including spine)
Each extremity

ORGAN SYSTEMS (OS)

PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH)

HPI
ROS
PFSH

Blood pressure, sitting
Blood pressure, lying
Pulse
Respirations
Temperature
Height
Weight
General appearance
(Counts as only 1)

1. Past illness, operations, injuries, treatments, and
current medications
2. Family medical history for heredity and risk
3. Social activities, both past and present

1
Problem
Focused

Documented

BODY AREAS (BA)

Constitutional (e.g., weight loss, fever)
Ophthalmologic (eyes)
Otolaryngologic (ears, nose, mouth, throat)
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breasts)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic

History Level

EXAMINATION ELEMENTS
CONSTITUTIONAL (OS)

Number of Key Components:
Code:

8+


Preface

xix

Each of the elements of the history, examination, and medical decision-making complexity is reviewed in the chapter in
detail. The coder will then complete an audit form for each of the E/M cases.
The E/M audit form is located in Appendix A of the text. The coder is to photocopy the audit form for each E/M case in the
text and for the tests that contain E/M cases. A blank copy of the form is located on the companion web page.

Report Format
Information is provided regarding a coding concept, such as pacemaker implantation:

Pacemaker

A pacemaker is an electrical device that is inserted into the body
to shock the heart electrically into regular rhythm. The two parts
of a pacemaker are the battery and electrode. The electrode is the
device that emits the electrical charge. The electrode is also called
the lead and is a flexible, thin tube. The battery is also called a
pulse generator. Some generators are programmable and have a
wide range of programming options. The pulse generator is placed
into a pocket either under the clavicle, as illustrated in Figure 6-4,
or under the muscle of the abdomen below the rib cage.
Either an epicardial or a transvenous approach can be used
to implant the electrode portion of the pacemaker. The epicardial
approach involves opening the chest to the view of the surgeon
and placing the device on the heart. The transvenous approach
is most commonly used because it is the least traumatic to
the patient; it involves inserting a needle with a wire attached
(guidewire) into a vein. The guidewire then directs the placement
of the electrode into the heart while the surgeon views the

progression using a fluoroscope. The electrode is then attached
to the pulse generator.

The pacemaker can be a single- or dual-chamber unit. A singlechamber pacemaker uses one pulse generator and one electrode
that is placed in either the atrium or the ventricle. A dual-chamber
pacemaker uses a pulse generator and two electrodes—one
placed in the atrium and the other placed in the ventricle.
Pacemakers can be permanent or temporary. A temporary
pacemaker can be used when the heart needs only short-term
pacing support, for example, when a patient is waiting for
placement of a permanent pacemaker or a patient is experiencing
postsurgical cardiac instability. After the pacemaker is placed, the
physician will test the device to ensure that it is operating correctly.
The pacemaker implantation report will indicate a statement such
as “thresholds were obtained and were adequate.” The testing
and setting are included in the implantation service and are not
reported separately. Special or extensive pacing, if noted in the
report as those above the usual service, can be reported separately.

As the text progresses, the coder is assigned more complex cases with fewer directives and less information to ensure the
development of the ability to transfer previously learned knowledge, thereby strengthening confidence in his/her coding and
auditing abilities. The goal of this text is to present the coder with a wide array of cases from across the major medical specialties.
These reports are the “real thing” from clinics and hospitals. The reports were selected to give you a realistic picture of the type
and scope of reports you will be coding on the job.
The format of the text is two columns to save space and contain the cost of production. Although the coder will not see a
two-column report on the job, it is the documentation that is important, in whatever format that information is presented. For
example, the pathology reports may be in the front of the medical record at one facility, and at another facility, the reports may
be in the back of the record. Or the coder may work exclusively with online rec­ords and never use the printed format.


xx

Preface

The coder assigns the service and diagnosis codes to reports. The following is an example of a report from the text:

6-5C Operative Report, Pacemaker Implantation
LOCATION: Outpatient, Hospital
PATIENT: Herbert Gillford
SURGEON: Marvin Elhart, MD
PROCEDURE PERFORMED: Dual-chamber pacemaker implantation
INDICATION: Bradyarrhythmia
BRIEF HISTORY: This patient has been experiencing recurrent syncope.
He was evaluated in the last year or so. Because of the presence of firstdegree AV (atrioventricular) block, sinus bradycardia, and bundle-branch
block, the cause for his syncope most likely is his bradyarrhythmia; for
that reason, a dual-chamber pacemaker implantation was recommended
after discussion with his cousin, who consented to the procedure. The
cousin was informed of all potential complications, including infection,
hematoma, pneumothorax, hemothorax, myocardial infarction, and even
death. He agreed to proceed.
PROCEDURE: The patient was brought to the cardiac catheterization
laboratory. He was placed on the catheterization table, where he was
prepped and draped in the usual fashion. The procedure was extremely
difficult to perform as a result of the patient’s agitation despite adequate
sedation. With reasonable hemostasis, the pacemaker pocket was
performed in the left infraclavicular area after anesthetizing the area
with 0.5 cc (cubic centimeter) of Xylocaine. Hemostasis was secured
with cautery. The patient had excessive venous oozing from Valsalva
and straining, and that was controlled with pressure. A single stick was
performed because of the patient’s agitation. Using a 9-French peel-away
sheath, we introduced an atrial and a ventricular lead and placed them in
an excellent position.

Thresholds were obtained adequately. The leads were sutured using 0 silk
over their sleeves and secured. The pulse generator was connected. The
pacemaker pocket was flushed with antibiotic solution. The pacemaker and
leads were placed in the pocket and the pocket closed in two layers.
COMPLICATION: None
EQUIPMENT USED: Pulse generator was Medtronic model 60 Thera DRI,
serial B28H. The ventricular lead was Medtronic serial L420V, model
4524 Link. The atrial lead was Medtronic 24-58, serial 326V.
The following parameters were obtained after implantation: Pacing
threshold in the atrium was excellent at 0.5 msec and 0.5 V, and impedance
was 445 ohms and sensing 2.1 mV. In the ventricle, 0.5 msec and 0.3 V with
R wave of 19.9 mV and impedance 668 (device evaluation).
The following parameters were left at implantation: DDDR with lower
rate limit of 70 and an upper rate limit of 120. The amplitude was 3.5 V
in the atrium at 0.4 msec with a sensitivity of 0.5 mV. The ventricle was
3.5 V and 0.4 msec at 2.8-mV sensitivity (device evaluation).
CONCLUSION: Successful implantation of dual-chamber pacemaker
without immediate complications.
PLAN: Patient to return to recovery unit and to be discharged late this
evening to the nursing home with routine postpacemaker care.

6-5C:
SERVICE CODE(S): _______________________________________
ICD-10-CM DX CODE(S): __________________________________
ICD-9-CM DX CODE(S): ___________________________________

Multiple Modifiers
Multiple modifiers are added to codes by placing the numbers first in ascending order, followed by the lettered modifiers
in alphabetic order. For example, if the code were to be reported with -55 and -RT, the -55 would be placed first, followed by
the -RT. Or as an another example, if the code were to be reported with -50 and -52, the -52 would be placed first, followed by

the -50. This is the format that is followed in this text.


Preface

xxi

Use of Modifiers -26 and -TC
n
n

Modifier -26 requests payment from the third-party payer for the professional component percentage of the fee only.
Modifier -TC requests payment for the technical component percentage of the fee only.

These modifiers are usually used with radiology and pathology services. An example is an independent radiology facility
that takes the x-rays (technical component) and sends them to a private radiologist who reads the x-rays and writes a report of
the findings (professional component). The independent radiology facility would report the service with the x-ray code with
modifier -TC added to indicate that only the technical component was provided. The physician’s services would be reported with
modifier -26 added to the x-ray code to indicate that only the professional component of the x-ray service was provided. If both
the technical and professional services of the x-ray were provided at the same place, such as the clinic, no modifiers would be
added, since both components of the service were provided at the same place and reporting the x-ray code without a modifier
requests the full fee from the carrier.
For the purposes of this text, the radiologist and pathologists are employed by the facility unless specifically stated otherwise.

Pathology and Laboratory
Chapter 4, Pathology and Laboratory, guides the coder in the use of a standard laboratory requisition or superbill as illustrated
on the following page.
When the coders have finished the activities within the chapter, they will have a completed laboratory requisition that
contains the codes for the tests listed. The coder will then be familiar with the most frequently ordered laboratory tests.

From the Trenches
”Coding elements and compliance regulations are constantly changing. The
continuing education process will always be essential.”
PATRICIA


xxii

Preface

Order Date:
Order Time:
PRIORITY (Routine unless otherwise specified)
ASAP
STAT
All tests:
Yes
No
If No, Specify Tests:
RECURRING ORDER (not to exceed 12 months)
Frequency:
Start Date:
SPECIAL INSTRUCTIONS

General Laboratory Requisition
Code
End Date:

FOR PHYSICIAN OFFICE COLLECTION ONLY:
Time:

By:
Collected: Date:
FOR LAB COLLECTION ONLY:
Collected: Date:
Time:
By:
Code CHEMISTRY
DX
TOXICOLOGY/
Albumin/Serum
Code THERAPEUTIC DRUGS DX
Alkaline phosphatase
Last Dose:
Carbamazepine
ALT/SGPT
Digoxin
Amylase
Lithium
Arterial Blood Gas
Phenobarbital
AST/SGOT
Phenytoin (Dilantin)
Bilirubin, direct
Salicylate
Bilirubin, total
Valproic Acid
BUN, Quant
Theophylline
Calcium, total
Carbon dioxide (CO2)

Code IMMUNOLOGY (Blood) DX
CEA
ANA (FANA) Screen
Chloride, blood
if ANA positive, 86039 titer
Cholesterol, serum
performed, if titer >1:160
CK (creatine kinase)
cascade performed (antiCreatinine, blood
ds DNA, ENA I & ENA II)
FSH
Anti-ds DNA
Ferritin
ENA I (Sm, RNP)
Folic Acid (Folate), blood
ENA II (SSA, SSB)
GGT
ASO screen (ASO titer if
Glucose, blood non-reag
screen positive 86060)
Glycated Hgb (Hgb A1C)
Rheumatoid factor (qual)
HCG-Qualitative
RPR (Syphilis Serology), quant
HCG-Quantitative
Cold Agglutinin titer
HDL Cholesterol
Hep B surface antigen
-90 Immun. Electrophoresis
-90 Hep B surface antigen

Iron
OB (PHL)
Iron Binding Capacity
-90 HIV
NC
% saturation requires
Mono test
iron & IBC to be ordered
Rubella Antibody
LDH (lactate dehydrogenase)
LH (luteinizing hormone)
Magnesium
DX
Phosphorus, blood
Code PANELS
Electrolytes CO2, Cl, K, Na
Potassium, blood
Bas Met, cal ion
Prolactin, blood
Bas Met, cal tot
Protein, total
Comprehensive metabolic
-90 Protein Electrophoresis, serum
Alb, Bili tot, Ca tot, Cl, Creat,
PSA, total
Glu, Alk phos, K, Prot tot,
Sodium, serum
Na, AST, ALT, BUN, CO2
T4, free (thyroxine)
Hepatic Function

TSH
Alb, Bili tot and dir, Alk phos,
Triglycerides
AST, ALT, Prot tot
Uric Acid, blood
Lipid Chol tot, HDL, Trig.,
Vitamin B12
calc, LDL, Chol/HDL ratio
CALCULATIONS
Gen health, Comp met,
NC
LDL requires Chol & HDL
CBC, TSH
to be ordered
NC
CHOL/HDL requires Chol
& HDL to be ordered
Chart #:
Name:
DOB:
Physician:

Date:
M/F

DX
HEMATOLOGY
Hemogram
WBC, auto WBC diff
Hemogram

micro exam, WBC diff
Hemogram
micro exam, w/o diff
Hemogram
manual WBC diff, buffy
Hematocrit
Hemoglobin
Platelet count, auto
Hours:
Reticulocyte count, manual
Sedimentation Rate, auto
WBC, automated
CBC, with diff

DX
URINE/STOOL
UA, Routine
UA SAVE (for possible
urine culture if requested)
UA with microscopic
Urinalysis, Dipstick, Lab
Occult Blood
Urine HCG
Diabetic urine cascade

Code

Code

TIMED URINE

DX

Creatinine Clearance
Calcium, Urine, Quant.
Uric acid

Hgb, Hct, RBC, WBC, Platelet

CBC, w/o diff
Code
Fluid Source:

Hgb, Hct, RBC, WBC, Platelet

Code COAGULATION
Coumadin
Heparin
APTT
Prothrombin time
Bleeding time

DX

Code

DX

OFFICE TESTING
UA, Dipstick in Office

WRITE-IN TESTS

BODY FLUID

DX

Cell Count w/o Diff
Protein
Glucose
Semen Analysis
Semen Analysis, Comp
Code IMMUNOHEMATOLOGY DX
Blood type ABO, Rh(D)
Weak D performed if
Rh negative
Antibody Screen
Identification, if positive,
titer if indicated
Direct Coombs
additional testing if
positive
DX
Lab Use

Medical Necessity Statement: Tests ordered on Medicare patients must follow CMS rules regarding medical
necessity and FDA approval guidelines and must include diagnosis, symptoms, or reason for testing as
indicated on the medical record. For any patient of any payor (including Medicare and Medicaid) that has a
medical necessity requirement, order only those tests which are medically necessary for the diagnosis and
treatment of the patient.

DX
1
2
3
4

CODE

WRITTEN INDICATION/DIAGNOSIS

LAB USE ONLY
Arterial Puncture
Venipuncture
Venipuncture MC/MA
Handling Fee
Urine Volume Measurement
-90 PKU

Medicare #:
Medicaid #:
No ABN needed
Patient refused to sign ABN
Nursing Home Part A Medicare:
Yes
No
Worker's Comp:
Yes
No
Company Account:

(Match Diagnosis # to Test)


Preface

xxiii

Glossary
There is a main glossary of terms that is a compilation of the more complex words from the text.

Evaluation
The tests contain at least two reports that are similar to ones that appeared in the chapter.

Web
The text has an accompanying website located at />
A Special Note
Coders are a very special group of individuals. They have keen minds and tend to be gifted with great patience for the detailoriented process of medical coding. They have immense professionalism and seek to do an exemplary job of the most difficult task
of translating services and diagnoses into codes and ensuring appropriate reimbursement. They are exemplified by a statement
made many years ago by Orison Swett Marden:

People who have accomplished work worthwhile have had a very high sense of the way to do things. They have not been
content with mediocrity. They have not confined themselves to the beaten tracks; they have never been satisfied to do things just
as others do them, but always a little better. They always pushed things that came to their hands a little higher up, a little farther
on. It is this little higher up, this little farther on, that counts in the quality of life’s work. It is the constant effort to be first class in
everything one attempts that conquers the heights of excellence.

Medical coding is a fine profession that has the ability to intrigue and captivate you for a lifetime. Practice your craft carefully,
with due diligence, patience for the process, and always the highest ethical standards.
Carol J. Buck, MS, CPC, CPC-H, CCS-P

Spend less time searching and more time learning with electronic access to The Next Step: Advanced Medical Coding and Auditing,
2014 Edition. With easy access from any computer or internet browser, you can search across all of your Elsevier e-textbooks,
paste important text and images from multiple sources into a focused, custom document, make notes, highlight, and more.
Please contact an Elsevier customer service representative for more information, or visit />

xxiv

Preface

The Top 10 List for Coders
Contributed by Karen D. Lockyer
10.  Abstracting is getting the essence of the relevant facts.
  9.  When in doubt, ASK—don’t assume anything.
  8.  Never be afraid to question a physician.
  7.  Work with good reference books.
  6.  Always use current code books.
  5.  Make notes in your coding manuals—it saves time later on.
  4.  Good coders are always learning.
  3.  Speed of record reading comes with practice; never sacrifice accuracy.
  2.  If it isn’t documented, it didn’t happen.
  1.  NEVER CODE DIRECTLY FROM THE INDEX OF A CODE MANUAL!
Some of the CPT code descriptions for physician services include physician extender services. Physician extenders, such
as nurse practitioners, physician assistants, and nurse anesthetists, etc., provide medical services typically performed by a
physician. Within this educational material, the term “physician” may include “and other qualified health care professionals,”
depending on the code. Refer to the official CPT® code descriptions and guidelines to determine codes that are appropriate
to report services provided by nonphysician practitioners.


Acknowledgments

This text was developed through a team effort. Each member of the team was vital for the completion of this volume of work.
Each person shared the vision for an advanced coding text that would enable the learner to be better prepared to meet the exciting challenge presented by medical coding.
Special thanks goes to the team of wonderful people at Elsevier. Your professionalism, amazing skill, and genuine desire to
assist in the educational process by providing high-quality texts are readily apparent and greatly appreciated.
Sheri Poe Bernard, Senior Technical Collaborator, whose knowledge of coding and strong editing skill have improved our
content.
Jackie Grass, Senior Coding Specialist, who cares deeply about students and is always willing to share her skill in accomplishment of the most formidable tasks for them, and without whose effort this text would have been an impossible task.
John W. Danaher, President, Education, and Sally Schrefer, former Executive Vice President, Nursing/Health Sciences, with
keen insights, ingenuity, and excellent problem-solving abilities, make the process work.
Andrew Allen, Vice President and Publisher, Health Professions, with his mild manner, wit, and patience, helps keep the
team focused on the ultimate goal.
Jeanne R. Olson, Content Strategy Director, who has tremendous enthusiasm for our mission.
Helen O’Neal, Associate Content Development Specialist, who has shouldered the huge task of seeing this text to completion
with an exceptional level of professionalism. She is the consummate professional who improves all she is involved with.
Lindsay Gilmer, Production Editor, Graphic World, who has assumed responsibility while maintaining a high degree of
professionalism.
Patricia Cordy Henricksen, Query Manager, who never fails to amaze us all with her knowledge and ability to clarify the
most complex coding issue.
The publisher would like to acknowledge and thank the following people:
Judy Breuker, Teasee Foreman, David S. Brigner, Lynda Kross, Joan E. Wolfgang, Robert Ekvall, Thomas Mobley,
Nancy Maguire, Kathy Pride, John Neumann, Jolean Boutwell, Sharon Oliver, and Linda Farrington for their enthusiasm
for coding and dedication to the profession.
Dan Kaufman of Las Vegas Photo & Video for his talent, patience, and photographs.

xxv