SECTION TWO In this section, intermediate guided practice coding scenarios are presented for the physi- cian office, outpatient hospital, and inpatient hospital settings. Each chapter in this sec- tion presents Let’s Practice exercises, which guide students through the analysis of medical documentation and provide helpful hints, coding steps, and the final codes for each scenario. Each chapter ends with Review Cases, where students are expected to apply their knowledge to code various types of medical documentation on their own. Chapter 3: Intermediate Physician Office Coding Chapter 4: Intermediate Outpatient Hospital Coding Chapter 5: Intermediate Inpatient Hospital Coding Intermediate Coding: A Guided Approach
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SECTION TWO
In this section, intermediate guided practice coding scenarios are presented for the physi-
cian offi ce, outpatient hospital, and inpatient hospital settings. Each chapter in this sec-
tion presents Let’s Practice exercises, which guide students through the analysis of
medical documentation and provide helpful hints, coding steps, and the fi nal codes for
each scenario. Each chapter ends with Review Cases, where students are expected to
apply their knowledge to code various types of medical documentation on their own.
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INTERMEDIATE PHYSICIAN OFFICE CODING
Key Terms ICD-9-CM Offi cial Guidelines for Coding and Reporting — offi cial coding guidelines provided by CMS
and NCHS that are to be followed when assigning ICD-
9-CM codes until the October 1, 2014 implementation date
of ICD-10-CM and ICD-10-PCS
inpatient— a patient who is formally admitted to a facility
for treatment
outpatient— a patient who is not formally admitted to
a facility
3 3 Learning Objectives
After reading this chapter, you should be able to:
• Spell and defi ne the key terms presented in this chapter.
• Defi ne the purpose of physician’s offi ce coding.
• Describe the different types and sources of physician documentation.
• Describe the guidelines used by the physician’s offi ce coder.
• Understand the difference between physician coding and facility coding.
• Differentiate among the settings physician’s offi ce coders code for.
• Apply the steps required to code physician’s offi ce cases correctly.
CPT-4 codes in this chapter are from the CPT-4 2012 code set. CPT is a registered trademark of the American Medical Association.
ICD-9-CM codes in this chapter are from the ICD-9-CM 2012 code set from the Department of Health and Human Services, Centers for Disease
Control and Prevention.
ICD-10-CM codes in this chapter are from the ICD-10-CM 2012 Draft code set from the Department of Health and Human Services, Centers for
Disease Control and Prevention.
INTRODUCTION The coding profession is a growing fi eld and there
are a variety of employment opportunities for coders.
Coders can work in various settings including hospitals,
physician’s offi ces, insurance companies, law fi rms, public
health agencies, worksite health systems, and prison sys-
tems, to name a few. This chapter discusses physician’s
offi ce coding and the role and activities of a physician
coder. It presents the steps a physician’s offi ce coder takes
to complete the coding process for the diagnoses and pro-
cedures that a physician must report for reimbursement.
PHYSICIAN CODING The physician’s offi ce is a unique coding setting for cod-
ing professionals. The physician’s offi ce is an outpatient
setting, but the physician may see patients in both outpa-
tient and inpatient settings. Inpatients are those who are
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CHAPTER 3 Intermediate Physician Office Coding 37
Outpatient Coding Guidelines The physician’s offi ce coder will access administrative and
clinical data for each specifi c patient encounter per docu-
mentation in order to properly assign diagnosis and pro-
cedure codes. The physician’s offi ce coder uses the current
ICD-9-CM outpatient coding guidelines when determin-
ing the diagnostic statement(s) to be coded. (To access
these guidelines, see Appendix A .)
Upon implementation of ICD-10-CM, the physician’s
offi ce coder will adhere to the outpatient coding guide-
lines for ICD-10-CM. One of the most important outpa-
tient coding guidelines to remember as a coder is that you
cannot code suspected, probable, possible, or likely diag-
noses in an outpatient setting. A diagnosis that is sus-
pected, probable, possible, or likely is only coded by
inpatient facility coders.
Coding in the Physician’s Offi ce Setting The fi rst step in coding in the physician’s offi ce setting is
to identify the appropriate setting in which you are cod-
ing, such as the physician’s offi ce, nursing home, inpa-
tient admission, or a physician’s offi ce consultation. The
second step is to determine the reason for the visit by
thoroughly reading through the documentation to see
what warranted the patient’s visit, which would be the
diagnosis(es). The third step is to determine what proce-
dures and/or services were performed. Step 4 is to locate
the correct diagnosis code using the current year’s ICD-
9-CM coding, Volumes 1 and 2, which will be replaced
with ICD-10-CM on October 1, 2014. Step 5 is to verify
diagnosis(es) codes in the ICD-9-CM Tabular Index.
Step 6 is to locate the correct procedure code using the
CPT-4 coding manual. The fi nal step is to read the proce-
dure code description to ensure it matches your scenario,
and then check to see if a modifi er is also needed. In the
outpatient setting, coders must adhere to the ICD-9-CM
Offi cial Guidelines for Coding and Reporting and Diag-nostic Coding and Reporting Guidelines for Outpatient Services, which state that only the highest known or defi nitive
diagnosis is assigned a code. If a defi nitive diagnosis has
not been determined, then signs and symptoms and/or
chief complaint should be utilized for coding. Do not
assign codes for diagnoses documented as probable,
formally admitted to a facility for treatment. Outpatients
are those who are seen without being formally admitted
to the facility. Therefore, the coding professional working
in the physician’s offi ce may be assigning codes for both
outpatient and inpatient services provided by the physi-
cian. The outpatient services a physician coder might
code for include items a physician provides to patients in
the offi ce setting or hospital outpatient setting, whereas
inpatient services a physician coder will code for are
those hospital services that the physician provides to his
or her patients who have been admitted to a facility as
inpatients.
The purpose of coding in the physician’s offi ce setting
is to obtain reimbursement for services provided and to
be able to retrieve information regarding diagnoses, pro-
cedures, and other identifi ers important to the individual
physician. The reimbursement form utilized by physi-
cians’ offi ces is the CMS-1500 claim form ( ■ FIGURE 3-1 ).
Physician Documentation Standard formats for the health records found in the phy-
sician’s offi ce were traditionally identifi ed as source ori-
ented, integrated, problem oriented, and other mixed
formats based on individual physician preference. The
electronic health record in the physician’s offi ce contains
the same information as the traditional paper health
record. Sources of documentation for physician services
are found in many provider locations. Physician’s offi ce
coders may fi nd themselves assigning codes for patient
encounters in clinics and offi ces, inpatient hospitals, out-
gery centers, urgent care clinics, and observation,
long-term care, skilled nursing, home health, or other
settings.
As discussed in Chapter 2 , documentation includes
administrative and clinical data. The basic documenta-
tion in the physician’s offi ce is also grouped into these
categories. Administrative data includes registration
information such as patient demographics, release of
information forms, and fi nancial information to include
assignment of benefi ts. Clinical data contains the prob-
lem list; medication list; medical history; physical exami-
nation; physician orders, which are often combined with
progress notes; progress notes; diagnostic reports such
as radiology reports; operative reports; and/or procedure
reports.
Physician’s offi ce coding currently utilizes ICD-9-CM
diagnoses codes, Volumes 1 and 2, and will continue to do
so until the DHHS offi cial implementation date of Octo-
ber 1, 2014 for the use of ICD-10-CM. Physician evalu-
ation and management and procedure codes are assigned
using CPT-4 ® codes. ICD-9-CM procedure codes,
Volume 3, or ICD-10 PCS codes are not utilized in the
physician’s offi ce setting.
CODING TIP
To begin preparing for the ICD-10-CM and ICD-10-PCS
implementation, check out the information provided on
the following website: www.icd10data.com .
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38 SECTION TWO Intermediate Coding: A Guided Approach
1a. INSURED’S I.D. NUMBER (For Program in Item 1)
4. INSURED’S NAME (Last Name, First Name, Middle Initial)
7. INSURED’S ADDRESS (No., Street)
CITY STATE
ZIP CODE TELEPHONE (Include Area Code)
11. INSURED’S POLICY GROUP OR FECA NUMBER
a. INSURED’S DATE OF BIRTH
b. EMPLOYER’S NAME OR SCHOOL NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorizepayment of medical benefits to the undersigned physician or supplier forservices described below.
SEX
F
HEALTH INSURANCE CLAIM FORM
OTHER1. MEDICARE MEDICAID TRICARE CHAMPVA
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignmentbelow.
MM DD YY15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.
GIVE FIRST DATE MM DD YY14. DATE OF CURRENT:
19. RESERVED FOR LOCAL USE
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)
FromMM DD YY
ToMM DD YY
1
2
3
4
5
625. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?
(For govt. claims, see back)
31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverseapply to this bill and are made a part thereof.)
SIGNED DATE
SIGNED
MM DD YY
FROM TO
FROM TO
MM DD YY MM DD YY
MM DD YY MM DD YY
CODE ORIGINAL REF. NO.
$ CHARGES
28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE
$ $ $
PICA PICA
2. PATIENT’S NAME (Last Name, First Name, Middle Initial)
5. PATIENT’S ADDRESS (No., Street)
CITY STATE
ZIP CODE TELEPHONE (Include Area Code)
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)
a. OTHER INSURED’S POLICY OR GROUP NUMBER
b. OTHER INSURED’S DATE OF BIRTH
c. EMPLOYER’S NAME OR SCHOOL NAME
d. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO
( )
If yes, return to and complete item 9 a-d.
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
20. OUTSIDE LAB? $ CHARGES
22. MEDICAID RESUBMISSION
23. PRIOR AUTHORIZATION NUMBER
MM DD YY
CA
RR
IER
PA
TIE
NT
AN
D IN
SU
RE
D IN
FO
RM
AT
ION
PH
YS
ICIA
N O
R S
UP
PL
IER
INF
OR
MA
TIO
N
M F
YES NO
YES NO
1. 3.
2. 4.
DATE(S) OF SERVICEPLACE OFSERVICE
PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.
EMGRENDERING
32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #
NUCC Instruction Manual available at: www.nucc.org
c. INSURANCE PLAN NAME OR PROGRAM NAME
Full-Time Part-Time
17b. NPI
a. b. a. b.
NPI
NPI
NPI
NPI
NPI
NPI
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05
G.EPSDTFamilyPlan
ID.QUAL.
NPI NPI
CHAMPUS
( )
1500
APPROVED OMB-0938-0999 FORM CMS-1500 (08-05)
Figure 3-1 ■ CMS-1500 form utilized for physician office billing. Source: www.cms.gov
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CHAPTER 3 Intermediate Physician Office Coding 39
suspected, questionable, rule out, or working diagnosis . A
chronic disease requiring ongoing treatment can be coded
multiple times as long as the disease is documented and a
treatment was required that affected patient care or man-
agement during each specifi c episode of care for the dis-
ease. Conditions that no longer exist are not assigned
codes. Be sure to look for history codes if an historical
condition has an impact on the current episode of care.
Physician’s offi ce coders may also code for outpatient
surgery services performed by the physician and will uti-
lize the history and physical, physician orders/progress
notes, operative report, and pathology report as source
documents. The postoperative diagnosis is used as the
CODING TIP
When determining the physician’s E/M, code level, it is
helpful to have an E/M “cheat sheet,” which can be found in
a variety of resources. Most specialties will have their own
specific E/M cheat sheet, and some general family practice
ones are available from www.aafp.org . ■ FIGURE 3-2 shows
sample E/M computer wallpaper from Brown Consulting
that can be utilized to help physician coders arrive at the
correct E/M level.
For additional information, visit www.aaos.org/news/
bulletin/may07/managing7.asp
CODING TIP
A physician can choose to use either the 1995 or the 1997
E/M coding guidelines. Follow these steps to access the
CMS document that includes both the 1995 and 1997 E/M
coding guidelines:
1. Go to www.cms.gov .
2. Search the Outreach and Education category.
3. Go to the Medicare Learning Network (MLN) products and
search for the evaluation and management services guide.
defi nitive diagnosis, not the preoperative diagnosis. Be
sure to correlate the postoperative diagnosis with the
corresponding pathology report. Read the entire opera-
tive report in order to ascertain the exact procedure that
was performed, and then be guided by the procedure
performed documentation on the operative report.
Inpatient setting codes for physicians are based on doc-
umentation found in the history and physical, physician
orders/progress notes, operative report, and discharge sum-
mary. Physician’s offi ce coders who are coding for an inpa-
tient service the physician provided will assign diagnosis,
procedure, and evaluation and management (E/M) codes
for each day of service to the patient in the hospital setting.
Nursing Home Visit This is an annual nursing facility history and physical and
MDS/RAI evaluation for a 92-year-old female. This patient
has been a resident for three years. She has CHF, COPD,
and OA, all which remain stable with her current treatments.
● HELPFUL HINT: Go to E/M Other Nursing Facility
Services.
Steps:
1. Look up failure, heart, congestive.
2. Look up disease, lung, obstructive (chronic).
3. Look up osteoarthritis.
LET’S PRACTICE 3-1
4. Verify ICD-9 codes in the Tabular Index.
5. Determine the patient status.
6. Determine the patient service.
7. Determine the level of history, exam, and medical
decision making.
8. Verify CPT codes in the Tabular Index and check for
any applicable modifi ers.
Codes:
ICD-9: 428.0, 496, 715.90
ICD-10: I50.9, J44.9, M19.90
CPT: 99318
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40 SECTION TWO Intermediate Coding: A Guided Approach
Figure 3-2 ■ Brown Consulting’s Office/Clinic Coding Wallpaper. Reprinted with permission. Source: Brown Consulting
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CHAPTER 3 Intermediate Physician Office Coding 41
Figure 3-2 ■ continued
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42 SECTION TWO Intermediate Coding: A Guided Approach
Operative Report The 27-year old gravida 2, para 1 presented to my offi ce
at 11 weeks’ gestation. She had a normal pregnancy. Since
she had a C-section with her fi rst baby, we scheduled a
C-section for today, week 39, day 5 ( ■ FIGURE 3-3 ). I per-
formed a repeat low cervical transverse cesarean section,
which went well. She delivered a healthy male weighing
LET’S PRACTICE 3-4
8 lbs 4 oz., 21 inches long. Apgars were 8 and 9. We will
follow up with her in 4 weeks.
● HELPFUL HINT: This is a surgery and you do not
code an E/M with a surgery unless these are unrelated,
so do not assign an E/M code with this visit.
Initial Hospital Visit This is a 23-year-old female who was brought to the emer-
gency department because of a drug overdose. I am admit-
ting this patient to the ICU to further monitor and treat
her suicidal tendencies. The patient admitted to taking 1
bottle of Tylenol in an attempt to end her life. She has
recently broken up with her boyfriend of 2 years and states
that she does not wish to live without him. We will keep her
on suicide watch tonight and I will reevaluate in the a.m.
● HELPFUL HINT: Go to the Initial Hospital Admission
in the E/M section of your CPT coding manual.
Steps:
1. Go to the Table of Drugs and Chemicals.
2. Look up acetaminophen (which is the generic name
for Tylenol) and locate the code for poisoning and the
E-code for suicide attempt.
LET’S PRACTICE 3-2
3. Look up tendency, suicide.
4. Verify ICD-9 codes in the Tabular Index.
5. Determine the patient status.
6. Determine the patient service.
7. Determine the level of history, exam, and medical
decision making.
8. Verify codes in the Tabular Index .
Codes:
ICD-9: 965.4, 300.9,E950.0
ICD-10: T39.1x2A, F48.9
CPT: 99223
Initial Hospital Consultation I was called by Dr. Crews to see this patient. This patient
is a 65-year old female with adult-onset diabetes mellitus.
Dr. Crews is concerned about the gangrene occurring in
her foot and asked for an orthopedic consult. I examined
her left foot, which is obviously gangrenous and needs
surgical intervention. I discussed the options, surgery, and
risks with the patient and she has agreed to have this foot
amputated before the gangrene spreads into her leg. We
will proceed with surgery in the a.m.
● HELPFUL HINT: Go to the Initial Hospital Consulta-
tion in the E/M section of your CPT coding manual.
LET’S PRACTICE 3-3
Steps:
1. Look up diabetes, with gangrene.
2. Verify ICD-9 codes in the Tabular Index.
3. Determine the patient status.
4. Determine the patient service.
5. Determine the level of history, exam, and medical deci-
sion making.
6. Verify codes in the Tabular Index .
Codes:
ICD-9: 250.70, 785.4
ICD-10: E11.52
CPT: 99254
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CHAPTER 3 Intermediate Physician Office Coding 43
Fat
Bikini line incisionmade here
A caesarean delivery may be carried out as a planned procedure (in which case it is known as an elective caesarean) or as an emergency. Usuallythe surgical incision is made horizontally and low down, in the position known as the "bikini line".
Muscle
LET’S PRACTICE 3-4, continued
Steps:
1. Look up delivery, cesarean, previous cesarean section.
2. Look up Outcome of Delivery.
3. Verify ICD-9 codes in the Tabular Index.
4. Look up Cesarean Delivery.
5. Verify the codes in the Tabular Index .
Pathology Report
OPERATION: DILATATION AND CURETTAGE,
HYSTEROSCOPY
#1 ENDOMETRIAL CURETTAGE
#2 ENDOCERVICAL
Gross Description: Specimen #1 indicated as endome-
trial curettings are multiple, irregularly shaped fragments
of pink-tan tissue that together measure approximately 2.0
cm. The specimen is submitted in its entirety for examina-
tion. Specimen #2 indicated as endocervical curettings are
multiple, irregularly shaped fragments of pink-tan tissue
and mixed with mucus and blood and together measuring
approximately 1.0 cm. The specimen is submitted in its