Acknowledgements
Introduction
Chapter 1 - Introducing Coders
Coding professionals
How coders think
Coder resources
Coder challenges
The bottom line in coding
Chapter 2 - The Rules
Who makes the rules?
Who enforces the rules?
Who uses the two coding systems?
Basic ICD-9-CM rules
Inpatient
Outpatient / physician diagnosis
Diagnosis coding
Procedure coding
Basic CPT rules
Procedure coding
Coding concepts
Site
Laterality
Cause and effect
Symptoms
A Word about DRG’s and APC’s
Observation
V codes
Rules for physician queries
Why physicians are not the best coders
Chapter 3 - Diagnoses
How to use this section
Abdominal pain
Abortion
Alcohol use
Allergic reaction/adverse effect
toxicity/overdose
Anemia
Angina
Arthritis
Asthma
Back pain
Bites/stings
Breast cancer
Bronchitis
Burns
CAD/ASHD
Cardiac arrhythmias
Cardiomyopathy
Cataracts
Chest pain
CHF / pulmonary edema
Complications
Congenital / perinatal conditions
COPD
Cystocele/rectocele/prolapse
Dementia
Dermatitis
Diabetes
Drug abuse/addiction
Endometriosis
Fibroids
Follow-up
Fractures
Gastritis /ulcer
GI bleed
Glaucoma
Headache
Hemorrhoids
Hepatitis
Hernias
HIV
Hypertension
Hypo-/hyperthyroidism
Injuries
Mental disorders
Myocardial infarction
Neoplasms
Newborns
OB-Prenatal
OB-Delivery
Otitis
Pneumonia
Pre-op testing/screening
Renal insufficiency / failure
Septicemia vs. bacteremia
Stroke
Tuberculosis
UTI
Well patients
Chapter 4 – Procedures
How to use this section
Open vs. closed procedures
Eponymic procedures
Abortion
Amputation
Arthroplasty
Arthroscopy
Biopsies
Bladder suspension / colporrhaphy
Breast procedures
Bronchoscopy
Bunionectomy
CABG (Coronary Artery Bypass Graft)
Cardiac cath / PTCA / stent
Cataract removal
Chemotherapy
Colonoscopy / sigmoidoscopy
Cosmetic surgery
Cystoscopy / TURP / bladder tumors
Debridement
Destruction of skin lesions
EGD / esophagoscopy
Evaluation and management
Extraocular muscle procedures
Eyelid procedures
Fracture / dislocation treatment
Hardware removal
Hemorrhoidectomy
Hernia repair
Hysterectomy
Intestinal resection
Labor and delivery
Myringotomy / tympanoplasty
Osteopathic manipulative treatment
Pacemaker / AICD
Psychotherapy and assessment
Radiology – interventional
Retina procedures
Rhinoplasty / septoplasty
Sinus surgery
Skin grafts (free)
Skin grafts (flap)
Spine procedures
Tendon repair - hands
Thyroidectomy
Tongue procedures
Tonsillectomy / adenoidectomy
Varicose vein procedures
Vascular catheters
Wound repair
Appendix A - Excerpts from general inpatient
coding guidelines
Appendix B – Diagnostic coding and reporting
guidelines for outpatient services
(hospital-based and physician office)
Appendix C – ICD-9-CM coding for diagnostic tests
Appendix D – Modifiers
Appendix E – Data elements for general multi-system examination
Appendix F – E&M audit tool
Appendix G – ICD-10-PCS definitions of root operations
Appendix H – Standards of ethical coding
