SOLUTIONS MANUAL For Let's Code It! 2024-2025 Code Edition By Shelley Safian, All Chapters 1-41

SOLUTIONS MANUAL For Let's Code It! 2024-2025 Code Edition By Shelley Safian | All Solution Manual For Chapters 1-41 Let's Code It! 2024-2025 Code Edition By Shelley Safian Chapter 1-41 Chapter 1 - Introduction to the Language of Coding 2024 Compliant Learning Outcomes LO 1.1 Explain the four purposes of medical coding. LO 1.2 Identify the structure of the ICD-10-CM diagnosis coding manual. LO 1.3 Differentiate between the types of procedures and the various procedure coding manuals. LO 1.4 Examine the HCPCS Level II coding manual used to report the provision of equipment and supplies. Chapter Outline Learning Outcomes Key Terms The Purpose of Coding Medical Necessity Statistical Analyses Reimbursement Resource Allocations Diagnosis Coding Index to Diseases and Injuries [aka Alphabetic Index] Tabular List of Diseases and Injuries Ancillary Sections of ICD-10-CM Neoplasm Table Table of Drugs and Chemicals Index to External Causes The Format of ICD-10-CM Codes Procedure Coding Current Procedural Terminology (CPT) The Organization of the CPT Code Book

The Formats of CPT Codes International Classification of Diseases -10th Revision – Procedure Coding System (ICD-10PCS) The Format of ICD-10-PCS Codes HCPCS Level II Procedure Codes Equipment and Supplies The Format of HCPCS Level II Codes Chapter Summary Chapter 1 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Rules and Regulations

Chapter Overview Coding is not like anything you have ever studied before. No courses that you experienced in elementary, middle, or high school have prepared you for learning this skill. Biology and your science classes began your education that your anatomy and physiology class continued. Other courses you are taking as part of this program also typically connect to something, in some way, you have previously learned. As you begin this educational journey, you will use your critical thinking skills as well as some experiences you may have had as a patient yourself (or as the loved one of a patient). For the most part, though, this will be different, so prepare yourself for a new learning experience. In Part I, the chapters Introduction to the Languages of Coding, Abstracting Clinical Documentation, and The Coding Process share an overview of the concepts and skills you will apply in the chapters that follow. You will be introduced to the tools you have and will need to use as a professional coding specialist. Together, these three chapters create the foundation, the first layer, of a multilayered approach to learning coding. Then, the remaining Parts will share with you, one by one, the best practices for how to use each of these tools correctly. You will then be given many opportunities for hands-on practice so that you can build your skills and reinforce the knowledge you have obtained.

Discussion Activities 1. Discuss the different uses for medical (healthcare) coding. Learning Outcome: 1.1 The purpose of coding is to provide clear and precise communications between all parties that need to know, including: ∙ Medical necessity ∙ Statistical analyses ∙ Reimbursement ∙ Resource allocation 2. What are the sections of the ICD-10-CM coding manual and what role does each play in the coding process/ Learning Outcome: 1.2 The Alphabetic Index is the starting point, where one looks up the main terms used in the documentation to find a suggested code. The Tabular List provides additional specificity, along with guidance such as symbols and notations. The Official Guidelines for Coding and Reporting support accurate reporting, The Neoplasm Table, the Table of Drugs and Chemicals, and the External Cause Code Index all support accurate coding in an efficient and effective manner.

3. What code would you use? Learning Outcome: 1.3 and 1.4 Read this scenario then determine which type of procedure code or codes you would use. Explain why you chose this code(s). PATIENT: Johnson, Jeffrey ACCOUNT/EHR #: JOHNJEF001 ATTENDING PHYSICIAN: Calvin Arnold, MD A 69-year-old man was fit and well until earlier today when he was stung on the back of his right hand by a wasp. He had previously been stung on several occasions, the last time 2 weeks earlier. Within 5 min, he felt faint, followed shortly by a pounding sensation in his head and tightness of his chest. He collapsed and lost consciousness and, according to his wife, became grey and made gasping sounds. After 2-3 min, he regained awareness but lost consciousness immediately when his wife and a friend tried to help him to his feet. Fortunately, the emergency medical technicians (EMT) arrived in time to prevent him being propped up in a chair: they laid him flat, administered intramuscular injection of epinephrine (adrenaline) and intravenous antihistamines. He was then taken to the emergency department by ambulance. He had recovered fully by the next day. Answer: Injection of epinephrine = CPT for the injection; HCPCS Level II for the epinephrine

Intravenous antihistamines = CPT for the intravenous; HCPCS Level II for the antihistamines Ambulance service = HCPCS Level II Additional Resources Grey’s Anatomy Online: http://www.bartleby.com/107/ Stedman’s Medical Dictionary: http://www.stedmans.com/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html American Medical Association: http://www.ama-assn.org American Hospital Association: http://www.aha.org American Health Information Management Association: http://www.ahima.org AAPC: http://www.aapc.com ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 1 Review Answer Key Check It! Terminology: Answer: 1. L Treatment 2. B Condition 3. G Medical Necessity 4. J Reimbursement 5. E External Causes 6. C Diagnosis 7. I Procedure 8. A Classification System 9. F Inpatient 10. K Services 11. H Outpatient 12. D Eponym Learning Objective: 01.01 Learning Objective: 01.02 Learning Objective 01.03 Topic: The Purpose of Coding Topic: Diagnosis Coding Topic: Procedure Coding Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes

Let’s Check It! Concepts: 1. Answer: D all of these Feedback: Why is it so critical to code diagnoses and procedures accurately? The coding languages communicate information that is key to various aspects of the health care system, including Medical Necessity, Statistical analyses, Reimbursement, and Resource allocation. Learning Objective: 01.01 Topic: The Purpose of Coding Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty:1 Easy Est Time: 0-1 minute 2. Answer: D numbers or number-letter combinations Feedback: The professional coding specialist has the responsibility to accurately interpret health care terms and definitions (medical terminology) into numbers or number-letter combinations (alphanumeric codes) that specifically convey diagnoses and procedures. Learning Objective: 01.01 Topic: The Purpose of Coding Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty:1 Easy Est Time: 0-1 minute 3. Answer: C why the patient requires attention of the provider Feedback: A diagnosis explains WHY the patient requires the attention of a health care provider. Learning Objective: 01.01 Topic: The Purpose of Coding Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 4. Answer: B what the provider did for the patient Feedback: A procedure explains WHAT the physician or health care provider did for the patient. Learning Objective: 01.01 Topic: The Purpose of Coding

Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: A ICD-10-CM code book Feedback: The International Classification of Diseases – 10th Revision- Clinical Modification (ICD10-CM) code book contains all of the codes from which you will choose to report the reason why the health care professional cared for the patient during a specific encounter. Learning Objective: 01.02 Topic: Diagnosis Coding Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 6. Answer: C the Tabular List Feedback: The Alphabetic Index can only suggest a possible code to report the patient’s diagnosis, and you will use this suggestion to guide you to the correct page or subsection in the Tabular List. You must always turn to this suggested code in the Tabular List, to confirm it is accurate, or to find another code that might be better. Learning Objective: 01.02 Topic: Diagnosis Coding Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 7. Answer: D all of these Feedback: Diagnostic descriptions are listed by: • Condition (e.g., infections, fractures, and wounds) • Eponyms (e.g., Epstein-Barr syndrome and Cushing’s disease) • Other descriptors (e.g., history, family history). Learning Objective: 01.02 Learning Objective: 01.02 Topic: Diagnosis Coding Blooms: Remember

CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 8. Answer: C Arnold-Chiari disease Feedback: Diagnostic descriptions are listed by: • Condition (e.g., infections, fractures, and wounds) • Eponyms (e.g., Epstein-Barr syndrome and Cushing’s disease) • Other descriptors (e.g., history, family history). Learning Objective: 01.02 Topic: Diagnosis Coding Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 9. Answer: A injuries and poisoning Feedback: The Index to External Causes lists the causes of injury and poisoning. These codes are used to explain how a patient got injured, and where (place of occurrence) he or she was when the injury happened. As always, the code or codes must be confirmed in the Tabular List before you are permitted to report them. Learning Objective: 01.02 Topic: Diagnosis Coding Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 10. Answer: C H61.022 Feedback: An example of an ICD-10-CM code is H61.022: Chronic perichondritis of left external ear. H2031 is an example of a HCPCS Level II code 85460 is an example of a CPT code 08NTXZZ is an example of an ICD-10-PCS code Learning Objective: 01.02 Topic: Diagnosis Coding Blooms: Remember

CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 11. Answer: A there was a valid medical reason to provide care Feedback: The diagnosis codes that you assign explain the justification for the procedure, service, or treatment provided to the patient during the encounter. Every time a health care professional provides care to a patient, there must be a valid medical reason. Certainly, everyone would agree that health care professionals must have a good reason to perform procedures on a patient. This is referred to as medical necessity. Learning Objective: 01.01 Topic: The Purpose of Coding Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 12. Answer: C what Feedback: The WHY justifies the WHAT = Requiring medical necessity ensures that the health care provider is not performing tests and giving injections without a good medical reason. Diagnosis codes explain why the individual came to see the physician and support the physician’s decision about what procedures to provide. Learning Objective: 01.01 Topic: The Purpose of Coding Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 13. Answer: B procedure Feedback: Once the physician has determined the patient’s condition or problem, he or she can then determine how to treat it. Generally, there are three terms used to describe actions that the physician takes to support the patient’s good health or to improve a current condition: Procedures are actions, or series of actions taken to accomplish an objective (result). For example, surgically removing a mole or re-sectioning the small intestine. Services are actions that will, more often, involve counseling, educating, and advising the patient, such as discussing test results or sharing recommendations for risk reduction.

Treatments are, typically, an application of a health care product, such as radiation treatments for tumor reduction or acupuncture. Learning Objective: 01.03 Topic: Procedure Coding Blooms: Remember CAAHEP: IX.C.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 14. Answer: A Diagnostic Feedback: Actions provided by the physician or other health care professional, are done for one of three reasons: Diagnostic tests or procedures are performed to provide the physician with additional information to support the determination of a confirmed diagnosis. Preventive procedures and services are provided to keep a healthy patient healthy. In other words, to avoid illness or injury. These will also include early detection testing, known as screenings. Therapeutic procedures, treatments, and services are performed with the intention of removing, correcting, or repairing an abnormality or condition. Learning Objective: 01.03 Topic: Procedure Coding Blooms: Remember CAAHEP: IX.C.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 15. Answer: D all of these Feedback: There are three (3) different code sets available for you to use in the process of translating health care procedures, services, and treatments into codes. These three code sets are: Current Procedural Terminology (CPT) Healthcare Common Procedure Coding System (HCPCS) Level II International Classification of Diseases – 10th Revision – Procedure Coding System (ICD-10PCS) Learning Objective: 01.03 Topic: Procedure Coding Blooms: Remember CAAHEP: IX.C.1 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 1 Easy Est Time: 0-1 minute 16. Answer: B 6 Feedback: The main body of the CPT book has six sections, presented in numerical order (generally speaking) by code number: • Evaluation and Management: 99201–99499 • Anesthesia: 00100–01999 and 99100–99140 • Surgery: 10021–69990 • Radiology: 70010–79999 • Pathology and Laboratory: 80047–89398, 0001U-0017U • Medicine: 90281–99199, 99500–99607 Learning Objective: 01.03 Topic: Procedure Coding Blooms: Remember CAAHEP: IX.C.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 17. Answer: B 1134F Feedback: Category II codes: used for supplemental tracking of performance measurements. Category II codes are five-character codes: four numbers followed by the letter F: for example, 1134F Episode of back pain lasting 6 weeks or less. 89398 is an example of a CPT code V95.9 is an example of an ICD-10-CM external cause code 0241T is an example of an of a CPT category III code Learning Objective: 01.03 Topic: Procedure Coding Blooms: Remember CAAHEP: IX.C.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 18. Answer: C ICD-10-PCS code book Feedback: The International Classification of Diseases – 10th Revision – Procedure Coding System (ICD-10-PCS) is the code set used for hospital facility reporting of the procedures, services, and treatments provided to a patient who has been admitted as an inpatient. Learning Objective: 01.03 Topic: Procedure Coding

Blooms: Remember CAAHEP: IX.C.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 19. Answer: B one letter followed by four numbers Feedback: The codes listed in the HCPCS Level II code book are all structured the same way: one letter followed by four numbers. No dots, no dashes. Learning Objective: 01.04 Topic: Equipment and Supplies Blooms: Remember CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 20. Answer: A J3285 Feedback: An example of a HCPCS Level II code is J3285: Injection, treprostinil, 1mg D7056ZZ is an example of an ICD-10-PCS code 58940 is an example of a CPT code T84.010D is an example of an ICD-10-CM code Learning Objective: 01.04 Topic: Equipment and Supplies Blooms: Remember CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Rules and Regulations 1. Answer: In most cases, there are three parties involved in virtually every encounter: the health care provider; the patient; and the person or organization paying for the care provided (frequently, a health care insurance company). However, the insurance company is not always an actual insurance company, so the broader term “third-party payer” is used. Third-party payers use our coding data to determine how much they should pay health care professionals for the attention and services they provide patients. This is the role that coding plays in the

reimbursement process. The codes make it easier for the organizations involved to evaluate and manage all their data. In most cases, there are three parties involved in reimbursement:  The health care provider = First Party  The patient = Second Party  The insurance company or other organization financially responsible = Third-party payer Feedback: In most cases, there are three parties involved in virtually every encounter: the health care provider; the patient; and the person or organization paying for the care provided (frequently, a health care insurance company). However, the insurance company is not always an actual insurance company, so the broader term “third-party payer” is used. Third-party payers use our coding data to determine how much they should pay health care professionals for the attention and services they provide patients. This is the role that coding plays in the reimbursement process. The codes make it easier for the organizations involved to evaluate and manage all their data. In most cases, there are three parties involved in reimbursement:   

The health care provider = First Party The patient = Second Party The insurance company or other organization financially responsible = Third-party payer

Learning Objective: 01.01 Topic: The Purpose of Coding Blooms: Understand CAAHEP: VIII.C.1.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 Minutes 2. Answer: The Tabular List provides you with each and every available code in ICD-10-CM, in order of the code characters – alphanumeric order: A00 through Z99.89. You need to carefully read the descriptions, beginning at the top of the subheading, so you can make certain that you find the best code, to the highest level of specificity, according to the physician’s notes for a particular encounter and following the directions of the book. The Alphabetic Index can only suggest a possible code to report the patient’s diagnosis, and you will use this suggestion to guide you to the correct page or subsection in the Tabular List. You must always turn to this suggested code in the Tabular List, to confirm it is accurate, or to find another code that might be better. Feedback: The Tabular List provides you with each and every available code in ICD-10-CM, in order of the code characters – alphanumeric order: A00 through Z99.89. You need to carefully read the descriptions, beginning at the top of the subheading, so you can make certain that you find the best code, to the highest level of specificity, according to the physician’s notes for a particular encounter and following the directions of the book. The Alphabetic Index can only suggest a possible code to report the patient’s diagnosis, and you will use this suggestion to guide you to the correct page or subsection in the Tabular List. You must

always turn to this suggested code in the Tabular List, to confirm it is accurate, or to find another code that might be better. Learning Objective: 01.02 Topic: Diagnosis Coding Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 Minutes 3. Answer: Diagnostic tests or procedures are performed to provide the physician with additional information required to determine a confirmed diagnosis. Preventive procedures and services are provided to keep a healthy patient healthy. In other words…to avoid illness or injury. These also include early detection testing, known as screenings. Feedback: Diagnostic tests or procedures are performed to provide the physician with additional information required to determine a confirmed diagnosis. Preventive procedures and services are provided to keep a healthy patient healthy. In other words…to avoid illness or injury. These also include early detection testing, known as screenings. Therapeutic procedures, treatments, and services are performed with the intention of removing, correcting, or repairing an abnormality or condition. Learning Objective: 01.03 Topic: Procedure Coding Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 Minutes 4. Answer: The diagnosis codes that you assign explain the justification for the procedure, service, or treatment provided to the patient during the encounter. Every time a health care professional provides care to a patient, there must be a valid medical reason. Certainly, everyone would agree that health care professionals must have a good reason to perform procedures on a patient. This is referred to as medical necessity. Requiring medical necessity ensures that the health care provider is not performing tests and giving injections without a good medical reason. Diagnosis codes explain why the individual came to see the physician and support the physician’s decision about what procedures to provide. Medical necessity is one of the reasons it is so very important to code the diagnosis accurately and with all the specifics possible. If you are one number off, you

could accidentally cause the claim to be denied because the diagnosis, identified by the incorrect code, does not justify the procedure the doctor performed. Feedback: The diagnosis codes that you assign explain the justification for the procedure, service, or treatment provided to the patient during the encounter. Every time a health care professional provides care to a patient, there must be a valid medical reason. Certainly, everyone would agree that health care professionals must have a good reason to perform procedures on a patient. This is referred to as medical necessity. Requiring medical necessity ensures that the health care provider is not performing tests and giving injections without a good medical reason. Diagnosis codes explain why the individual came to see the physician and support the physician’s decision about what procedures to provide. Medical necessity is one of the reasons it is so very important to code the diagnosis accurately and with all the specifics possible. If you are one number off, you could accidentally cause the claim to be denied because the diagnosis, identified by the incorrect code, does not justify the procedure the doctor performed. Learning Objective: 01.01 Topic: The Purpose of Coding Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 Minutes

5. Answer: Not all insurance carriers accept HCPCS Level II codes, but Medicare and Medicaid want you to use them. It is your responsibility, as a coding specialist, to find out whether each thirdparty payer with which your facility works will permit the reporting of HCPCS Level II codes on a claim form. If not, you have to ask for the payer’s policies on reporting the services and supplies covered by HCPCS Level II. Feedback: Not all insurance carriers accept HCPCS Level II codes, but Medicare and Medicaid want you to use them. It is your responsibility, as a coding specialist, to find out whether each thirdparty payer with which your facility works will permit the reporting of HCPCS Level II codes on a claim form. If not, you have to ask for the payer’s policies on reporting the services and supplies covered by HCPCS Level II. Learning Objective: 01.04 Topic: Equipment and Supplies Blooms: Understand CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 Minutes

Chapter 2 Abstracting Clinical Documentation 2024 Compliant Learning Outcomes

LO 2.1 Identify which health care professional for whom you are coding. LO 2.2 Describe the process of abstracting physician documentation and operative notes. LO 2.3 Recognize the terms used to describe diagnoses in documentation. LO 2.4 Distinguish between co-morbidities, manifestations, and sequelae. LO 2.5 Determine those conditions that require external cause codes to be reported. LO 2.6 Recognize the terms used to describe procedures, services, and treatments provided. LO 2.7 Create a legal query to obtain documentation about a missing, ambiguous, or contradictory component in the existing documentation. Chapter Outline Learning Outcomes Key Terms For Whom You Are Reporting The Process of Abstracting Assume or Interpret Source Documents Abstracting the Documentation Reasons That Are Not Illness; Procedures That Are Not Actions Deconstructing Diagnostic Statements Dissect the Diagnostic Statement Recognize Inclusive Signs and Symptoms Identifying Manifestations, Co-morbidities, and Sequelae Manifestations Co-morbidities Sequela Reporting External Causes

Deconstructing Procedural Statements Interpreting for Each Code Set How to Query Writing the Query Query Pathways Chapter Summary Chapter 2 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! A Diagnosis or Procedure Let’s Check It! Rules and Regulations

Chapter Overview “If it is not documented, it didn’t happen. If it didn’t happen, you cannot code it!” The documentation is the source for all of the details required to begin the coding process. Therefore, the ability to abstract the main terms is necessary to establish a solid foundation for learning to code.

Discussion Activities 1. Explain, in your own words, the differences between “assuming” details and “interpreting”. Learning Objective: 2.2 Professional coding specialists must interpret the physician’s documentation. This does not include assuming in any way. Assuming is making up details, filling in the blanks with your own specifics, guessing, or substituting your own knowledge for missing facts. Interpreting is an exact science; it involves changing information from one language to another.

2. Explain how you use the prefixes, suffixes and roots of medical terminology to support interpreting the physician’s documentation. Learning Objective: 2.3 and 2.6 Being able to dissect the terms used by the physician in the patient record will help to interpret the details more accurately and effectively.

3. “Carly Camden, a 27-year-old female, was admitted into the hospital to have surgery on her broken leg” Write a query to the physician to obtain the details you need to determine the accurate and specific codes. HINT: Which leg is broken? What part of the leg is broken? What type of fracture is it? HINT: What procedure is being performed? Learning Objective: 2.7

Learning the importance of querying the physician and how to do this legally is important for all coders to understand, especially beginning coders who need to learn that asking for clarifications and additional details – whether from an instructor or a physician.

Additional Resources Grey’s Anatomy Online: http://www.bartleby.com/107/ Stedman’s Medical Dictionary: http://www.stedmans.com/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html American Medical Association: http://www.ama-assn.org American Hospital Association: http://www.aha.org American Health Information Management Association: http://www.ahima.org AAPC: http://www.aapc.com

ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 2 Review Answer Key Let’s Check It! Terminology Answer: 1. B Assume 2. J Symptoms 3. G Query 4. I Signs 5. D Demographic 6. E Interpret 7. H Sequela 8. F Manifestation 9. A Abstracting 10. C Co-morbidity Learning Objective: 02.02 Learning Objective: 02.03 Learning Objective: 02.04 Learning Objective: 02.07 Topic: The Process of Abstracting Topic: Deconstructing Diagnostic Statements Topic: Identifying Manifestations, Co-morbidities, and Sequelae Topic: How to Query Blooms: Remember CAAHEP: IX.C.2 ABHES: 4.a

CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minute Let’s Check It! Concepts 1. Answer: C for whom are you reporting? Feedback: The first question you, as the professional coder, will need to ask is… for whom are you reporting? Only then, will you know which main terms to look for as you abstract the operative notes, physician‘s notes, and reports. Learning Objective: 02.01 Topic: For Whom Are You Reporting Blooms: Remember CAAHEP: IX.C.2 ABHES: 4.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: B radiologist Feedback: The radiologist will have a coder to report for any imaging [e.g. xrays, MRI, CT scan, etc.]. Learning Objective: 02.01 Topic: For Whom Are You Reporting Blooms: Remember CAAHEP: IX.C.2 ABHES: 4.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: C A hospital Feedback: An acute care facility is a hospital. Learning Objective: 02.01 Topic: For Whom Are You Reporting Blooms: Remember CAAHEP: CAAHEP: IX.C.2 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 4.

Answer: B interpreting Feedback: One of the most challenging aspects of coding is the very fine line between assuming and interpreting. Yes, professional coding specialists must interpret the physician's documentation. This does not include assuming in any way. Assuming is making up details, filling in the blanks with your own specifics, guessing, or substituting your own knowledge for missing facts. Interpreting is an exact science; it involves changing information from one language to another. Learning Objective: 02.02 Topic: The Process of Abstracting Blooms: Remember CAAHEP: IX.C.2 ABHES: 4.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: C Physician‘s Notes/Operative Reports Feedback: Virtually every patient record should include all, or most, of these pages or sections:  Patient’s Registration Form: The patient‘s demographic information, as well as health insurance policy numbers, and the name of the individual who will be financially responsible. These details will be used for creation of the claim form and the billing process.  Referral Authorization Form: If another physician or health care provider referred this patient for a consultation, you will need to know this to determine the correct evaluation and management code. This information will be needed for the claim form, as well.  Physician’s Notes/Operative Reports: Written documentation of what occurred during this encounter between physician and patient. Also known as clinical documentation, this is your most important source for details required for you to determine the most accurate code or codes. Your job is to interpret the words – medical terminology – into codes. Your ability to interpret accurately is dependent upon your knowledge of anatomy and physiology, as well as medical terminology. This is the process known as abstracting.  Pathology and Laboratory Reports: Results of testing performed on blood, tissue, and other specimens hold important keys to the patient‘s condition. You are not permitted to report a code based on these results, however, your ability to understand what you read here may alert you to read carefully for a related diagnosis or perhaps sending a query to the attending physician.  Imaging Reports: Similar to pathology reports, these are reports written by a radiologist of his or her interpretations of images taken of the patient [e.g. x-ray, CT scan, MRI, etc.].



Medication Logs: If the facility is residential, such as an acute care hospital, skilled nursing facility, long term care facility, etc., the nursing staff must record every time they administer a medication to a patient, including the drug name, dosage, time administered, and route used for administration. This data will also need to be coded.  Allergy List: This list is included for the patient‘s safety so professionals can avoid giving the patient any substance to which he or she may be allergic. Learning Objective: 02.02 Topic: The Process of Abstracting Blooms: Remember CAAHEP: IX.C.2 ABHES: 4.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 6. Answer: B Read all the way through the clinical documentation for the specific encounter. Feedback: Abstracting is the first step in the coding process. You must read all clinical documentation related to the specific encounter all the way through, slowly and carefully. Whether the encounter was a short office visit or hourslong surgical procedure, you cannot assume that one sentence will give you a clear and entire picture of what occurred (the procedures or services) and why they were provided (the diagnosis or diagnoses). Remember, you learned about this in the Introduction to Code Sets chapter. You are required to code all diagnoses confirmed by the physician to be relevant during this encounter, not just those in the official diagnostic statement. The same stands for the procedures, as well. Learning Objective: 02.02 Topic: The Process of Abstracting Blooms: Remember CAAHEP: IX.C.2 ABHES: 4.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 7. Answer: A 1,1 Feedback: Every health care professional/patient encounter must have at least one reportable [codeable] reason why and at least one reportable [codeable] explanation of what. Learning Objective: 02.02 Topic: The Process of Abstracting Blooms: Remember

CAAHEP: IX.C.2 ABHES: 4.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 8. Answer: B acute Feedback: Now that you have identified all of the statements in the documentation that explain why the patient was cared for, take the statement apart and determine which word identifies the disease, illness, condition, or primary reason for the visit (also known as the ―main term‖). Separate this from any words that may simply describe the type of condition or the location of the condition (anatomical site/body site). The term ―acute‖ (which means severe) describes the type. Learning Objective: 02.03 Topic: Deconstructing Diagnostic Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 4.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 9. Answer: D hypersecretion Feedback: Hypersecretion is the condition. Learning Objective: 02.03 Topic: Deconstructing Diagnostic Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 10. Answer: B Section 1.B.5 Feedback: Official Guidelines: Section 1. B.4 Signs and Symptoms, 1.B.5 Conditions that are an integral part of a disease process, and 1. B.6 Conditions that are not an integral part of a disease process. Learning Objective: 02.03 Topic: Deconstructing Diagnostic Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 1 Easy Est Time: 0-1 minute 11. Answer: C second, first Feedback: A manifestation is a second condition CAUSED by the first condition. There are some diseases (also known as underlying conditions) that actually cause patients to develop other conditions. This second condition, directly the result of the first condition, is known as a manifestation. Learning Objective: 02.04 Topic: Identifying Manifestations, Co-morbidities, and Sequelae Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 12. Answer: B 2 Feedback: Coding a sequela requires at least two codes, in the following order: 1. The sequela condition, which is the condition that resulted and is being treated such as a scar or paralysis. 2. The sequela (late effect) or original-condition code with the seventh character ―S.‖ Learning Objective: 02.04 Topic: Identifying Manifestations, Co-morbidities, and Sequelae Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 13. Answer: C how, where Feedback: You learned in the Introduction to the Language of Coding chapter, that in addition to the why and the what, if a patient is injured, you will need to abstract details about how and where the patient became injured. Learning Objective: 02.05 Topic: Reporting External Causes Blooms: Remember CAAHEP: IX.C.2 ABHES: 4.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

14. Answer: D Y92.838 Feedback: An example of an external causes code would be Y92.838 - Other recreation area as the place of occurrence of the external causes. This code explains where the injury occurred. Learning Objective: 02.05 Topic: Reporting External Causes Blooms: Remember CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 15. Answer: B to repair Feedback: The suffix –plasty means to repair an example is Neuroplasty: neuro = nerves + -plasty = repair Learning Objective: 02.06 Topic: Deconstructing Procedural Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 16. Answer: A electrocardiography Feedback: ECG = Electrocardiography Learning Objective: 02.06 Topic: Deconstructing Procedural Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 17. Answer: D query the physician Feedback: Once you have completed abstracting the documentation, if you find that details you need to determine a specific code are not included, you may have to query the physician who wrote the documentation to get him or her to provide clarification or additional specifics. You learned the difference between assuming and interpreting. Therefore, you will need to ask the physician to add

the details you need to the patient‘s record, so you can move forward and determine the correct code. This is known as creating a query. Learning Objective: 02.07 Topic: How to Query Blooms: Remember CAAHEP: IX.C.2 ABHES: 4.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 18. Answer: C query the physician to gain the details needed to use a more specific code Feedback: Before using an unspecified diagnosis code, query the physician to gain the details needed to use a more specific code. Unspecified or NOS (not otherwise specified) codes should only be used as a last resort when the physician cannot be contacted. Learning Objective: 02.07 Topic: How to Query Blooms: Remember CAAHEP: IX.C.2 ABHES: 4.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 19. Answer: B B02.31 Feedback: The correct ICD-10-CM code that you would assign for Herpes Zoster, conjunctivitis would be B02.31. B02.31= Zoster conjunctivitis B02.31: ICD-10-CM index>herpes>zoster>conjunctivitis. Learning Objective: 02.03 Topic: Deconstructing Diagnostic Statements Blooms: Remember CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 20. Answer: C 77065 Feedback: The correct procedural (CPT) code that you would assign for a unilateral mammography would be 77065. 77065=mammography, unilateral. 77065: CPT Index>mammography Learning Objective: 02.06

Topic: Deconstructing Procedural Statements Blooms: Remember CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! A Diagnosis or Procedure 1. Answer: diagnosis, sprained Feedback: Sprained wrist, left, initial encounter: diagnosis, sprained Learning Objective: 02.03 Topic: Deconstructing Diagnostic Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: procedure, neurectomy Feedback: Tympanic neurectomy: procedure, neurectomy Learning Objective: 02.06 Topic: Deconstructing Procedural Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: diagnosis, bronchitis Feedback: Acute bronchitis: diagnosis, bronchitis Learning Objective: 02.03 Topic: Deconstructing Diagnostic Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4.

Answer: procedure, thrombolysis Feedback: Cerebral thrombolysis: procedure, thrombolysis Learning Objective: 02.06 Topic: Deconstructing Procedural Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 5. Answer: diagnosis, failure Feedback: Newborn circulatory failure: diagnosis, failure Learning Objective: 02.03 Topic: Deconstructing Diagnostic Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 6. Answer: procedure, laryngoplasty Feedback: Laryngeal web laryngoplasty: procedure, laryngoplasty Learning Objective: 02.06 Topic: Deconstructing Procedural Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 7. Answer: diagnosis, abscess Feedback: Cutaneous abscess of chest wall, initial encounter: diagnosis, abscess Learning Objective: 02.03 Topic: Deconstructing Diagnostic Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes

8. Answer: procedure, tracheostomy Feedback: Planned tracheostomy: procedure, tracheostomy Learning Objective: 02.06 Topic: Deconstructing Procedural Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 9. Answer: diagnosis, stenosis Feedback: Stenosis of the esophagus: diagnosis, stenosis Learning Objective: 02.03 Topic: Deconstructing Diagnostic Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 10. Answer: diagnosis, osteomyelitis Feedback: Ulna osteomyelitis: diagnosis, osteomyelitis Learning Objective: 02.06 Topic: Deconstructing Procedural Statements Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes Let’s Check It! Rules and Regulations 1. Answer: The professional coding specialists‘ motto: "If it isn't documented, it didn't happen. If it didn't happen, you can't code it!" If it is documented, there is no reason for you to assume about any details. Then, you only need to interpret that which is documented. Feedback: The professional coding specialists‘ motto: "If it isn't documented, it didn't happen. If it didn't happen, you can't code it!"

If it is documented, there is no reason for you to assume about any details. Then, you only need to interpret that which is documented. Learning Objective: 02.02 Topic: The Process of Abstracting Blooms: Understand CAAHEP: IX.C.2 ABHES: 4.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: One of the most challenging aspects of coding is the very fine line between assuming and interpreting. Yes, professional coding specialists must interpret the physician's documentation. This does not include assuming in any way. Assuming is making up details, filling in the blanks with your own specifics, guessing, or substituting your own knowledge for missing facts. Interpreting is an exact science; it involves changing information from one language to another. Just like casa = house (Spanish-to-English), fine needle aspiration = 10021 (medical terminology-to-CPT). This is why coding can be so challenging. We are responsible for not only translating from one language (medical terminology) to another (medical codes) but also for accurately figuring out into which language (CPT or ICD-10-CM or ICD-10-PCS or HCPCS Level II) medical terminology must be translated into. Another major factor is that no one is a natural born speaker of medical terminology, so you are required to learn a new language to understand the languages of medical coding. Imagine if you were born speaking English but you had to learn to speak French before achieving your ultimate goal of interpreting French words into Spanish. Feedback: One of the most challenging aspects of coding is the very fine line between assuming and interpreting. Yes, professional coding specialists must interpret the physician's documentation. This does not include assuming in any way. Assuming is making up details, filling in the blanks with your own specifics, guessing, or substituting your own knowledge for missing facts. Interpreting is an exact science; it involves changing information from one language to another. Just like casa = house (Spanish-to-English), fine needle aspiration = 10021 (medical terminology-to-CPT). This is why coding can be so challenging. We are responsible for not only translating from one language (medical terminology) to another (medical codes) but also for accurately figuring out into which language (CPT or ICD-10-CM or ICD-10-PCS or HCPCS Level II) medical terminology must be translated into. Another major factor is that no one is a natural born speaker of medical terminology, so you are required to learn a new language to understand the languages of medical coding. Imagine if you were born speaking English but you had to learn to speak French before achieving your ultimate goal of interpreting French words into Spanish.

Learning Objective: 02.02 Topic: The Process of Abstracting Blooms: Understand CAAHEP: IX.C.2 ABHES: 4.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: Official Diagnosis Guidelines Section 1.B.4 - Signs and symptoms: Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0 - R99) contains many, but not all codes for symptoms. See Section I.B.18 Use of Signs/Symptom/Unspecified Codes Feedback: Official Diagnosis Guidelines Section 1.B.4 - Signs and symptoms: Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0 - R99) contains many, but not all codes for symptoms. See Section I.B.18 Use of Signs/Symptom/Unspecified Codes Learning Objective: 02.03 Topic: Deconstructing Diagnostic Statements Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: Official Diagnosis Guidelines Section 1.B.10 - Sequela (Late Effects): A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Coding of sequela generally requires two codes sequenced in the following order: The condition or nature of the sequela is sequenced first. The sequela code is sequenced second.

An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect. See Section I.C.9. Sequelae of cerebrovascular disease See Section I.C.15. Sequelae of complication of pregnancy, childbirth and the puerperium See Section I.C.19. Application of 7th characters for Chapter 19 Feedback: Official Diagnosis Guidelines Section 1.B.10 - Sequela (Late Effects): A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Coding of sequela generally requires two codes sequenced in the following order: The condition or nature of the sequela is sequenced first. The sequela code is sequenced second. An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect. See Section I.C.9. Sequelae of cerebrovascular disease See Section I.C.15. Sequelae of complication of pregnancy, childbirth and the puerperium See Section I.C.19. Application of 7th characters for Chapter 19 Learning Objective: 02.04 Topic: Identifying Manifestations, Co-morbidities, and Sequelae Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: A co-morbidity is a condition that is active in the same body at the same time as another condition, however, there is no relationship between these two conditions - no cause and effect. These ―other diagnoses‖ may be referred to in the physician‘s documentation. However, only those conditions

that the physician has specifically evaluated, treated, ordered additional testing for, or those requiring additional monitoring, nursing care, or more time in the hospital should be reported with a code. Example: A pregnant patient fell and broke her leg. So, the pregnancy and the fracture are co-morbidities - they are two conditions present in the same patient at the same time. You know that being pregnant does not cause a fracture, and a fracture does not cause pregnancy. Which code will you report first? The code that is the reason for this encounter with the physician. So, if you are coding for an orthopedist, and the patient is here for a follow-up on the healing fracture, the fracture will be reported first. The pregnancy will also be reported (after the fracture code) because pregnancy is a systemic condition that this physician MUST take into consideration during the process of caring for this patient because the pregnancy will impact the treatment plan for the fracture. Feedback: A co-morbidity is a condition that is active in the same body at the same time as another condition, however, there is no relationship between these two conditions - no cause and effect. These ―other diagnoses‖ may be referred to in the physician‘s documentation. However, only those conditions that the physician has specifically evaluated, treated, ordered additional testing for, or those requiring additional monitoring, nursing care, or more time in the hospital should be reported with a code. Example: A pregnant patient fell and broke her leg. So, the pregnancy and the fracture are co-morbidities - they are two conditions present in the same patient at the same time. You know that being pregnant does not cause a fracture, and a fracture does not cause pregnancy. Which code will you report first? The code that is the reason for this encounter with the physician. So, if you are coding for an orthopedist, and the patient is here for a follow-up on the healing fracture, the fracture will be reported first. The pregnancy will also be reported (after the fracture code) because pregnancy is a systemic condition that this physician MUST take into consideration during the process of caring for this patient because the pregnancy will impact the treatment plan for the fracture. Learning Objective: 02.04 Topic: Identifying Manifestations, Co-morbidities, and Sequelae Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes

Chapter 3 The Coding Process 2024 Compliant

Learning Outcomes LO 3.1 Implement the six actions of the coding process. LO 3.2 Locate main terms in the Alphabetic Index. LO 3.3 Confirm the accurate code in the Tabular List, Main Section, or Tables. LO 3.4 Apply the Official Guidelines to ensure accurate code determination. LO 3.5 Analyze documentation and code selection to confirm medical necessity. Chapter Outline Learning Outcomes Key Terms The Coding Process Overview Action 1. Abstract the documentation Action 2. Query, if necessary Action 3. Code the diagnosis or diagnoses Action 4. Code the procedure or procedures Action 5. Confirm medical necessity Action 6. Double-check your codes The Alphabetic Indexes The Tabular List, Main Section, Tables, and Alphanumeric Section Full Code Descriptions Conventions (Notations and Symbols) ICD-10-CM CPT ICD-10-PCS HCPCS Level II The Official Guidelines ICD-10-CM CPT ICD-10-PCS Guidance Connection Confirming Medical Necessity Outpatient Settings Inpatient Setting Chapter Summary Chapter 3 Review Let‘s Check It! Terminology Let‘s Check It! Concepts Let‘s Check It! Guidelines Let‘s Check It! Rules and Regulations Chapter Overview There are six specific actions that students should take as part of the coding process. As they gain experience, it will take them less time to go through

these tasks. However, they must remember that time is not the number one consideration when coding—no matter what anyone says, accuracy is the most important factor. Following all of these actions every time they code will support their development of habits that will maintain accuracy throughout their careers. Discussion Activities 1. Explain, in your own words, why Action #6 is necessary for accurate coding. Learning objective: 3.1 Building the habit of checking one‘s own work, to identify and correct one‘s own mistakes before anyone sees this provides an opportunity for accuracy and success. 2. Explain the importance for the coder to confirm medical necessity before reporting codes. Learning objective: 3.5 The code or codes that are reported to identify the reasons why the patient required the attention of a health care professional justify what the physician or health care professional did to the patient or for the patient… but only when they are in accordance with the standards of care. Reimbursement is dependent upon medical necessity as well.

Additional Resources Grey’s Anatomy Online: http://www.bartleby.com/107/ Stedman’s Medical Dictionary: http://www.stedmans.com/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html American Medical Association: http://www.ama-assn.org American Hospital Association: http://www.aha.org American Health Information Management Association: http://www.ahima.org AAPC: http://www.aapc.com ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 3 Review Answer Key Let’s Check It! Terminology Answer: 1. A Alphabetic Index 2. I Tables 3. C Coding Process 4. B Alphanumeric 5. E Linking 6. F Main Section 7. D Official Guidelines

8. G Notations 9. H Symbols 10. J Tabular List Learning Objective: 03.01 Learning Objective: 03.02 Learning Objective: 03.03 Learning Objective: 03.04 Learning Objective: 03.05 Topic: The Coding Process Overview Topic: The Alphabetic Indexes Topic: The Tabular List, Main Section, Tables, and Alphanumeric Section Topic: The Official Guidelines Topic: Confirming Medical Necessity Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minute Let’s Check It! Concepts 1. Answer: D 6 Feedback: There are six specific actions that you should take to construct your proper coding process. Action 1. Abstract the documentation. Action 2. Query, if necessary Action 3. Code the Diagnosis or Diagnoses Action 4. Code the Procedure or Procedures. Action 5. Confirm Medical Necessity Action 6. Double-Check Your Codes Learning Objective: 03.01 Topic: The Coding Process Overview Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2.

Answer: B accuracy of codes Feedback: Remember that time is not the number one consideration when coding—no matter what anyone says, accuracy is the most important factor and you will need all of these actions to maintain accuracy. Learning Objective: 03.01 Topic: The Coding Process Overview Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: A 1 Feedback: Action 1. Abstract the documentation. Read completely through the physician‘s notes for the encounter, from beginning to end. Then, reread the documentation and identify the key words regarding diagnoses (why) and procedures (what) directly related to the encounter. Remember, if the patient is injured, you will need to identify the external causes (how and where), as well. Learning Objective: 03.01 Topic: The Coding Process Overview Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 4. Answer: C confirm medical necessity Feedback: Action 5. Confirm Medical Necessity  Link each and every procedure code to at least one diagnosis code to verify medical necessity.  Remember, every encounter between patient and health care professional must have at least one diagnosis code and at least one procedure code. Learning Objective: 03.01 Topic: The Coding Process Overview Blooms: Remember

CAAHEP: IX.C.5 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: C 1, 1 Feedback: Remember, every encounter between patient and healthcare professional must have at least one diagnosis code and at least one procedure code. One diagnosis code can link to more than one procedure code, but it must link to at least one. One procedure code may link to more than one diagnosis code, but it must link to at least one. Learning Objective: 03.01 Topic: The Coding Process Overview Blooms: Remember CAAHEP: ABHES: CAHIIM: Level of Difficulty: 1 Easy Est Time: 0-1 minute 6. Answer: C Alphabetic Index Feedback: Once you have abstracted the main terms that describe the diagnosis (why) and the procedure (what) from within the physician documentation or operative reports, the next action is to determine the codes that accurately report these details. You will begin by matching those main terms to an entry in the appropriate code book's Alphabetic Index.

Learning Objective: 03.02 Topic: The Alphabetic Indexes Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

7. Answer: A ICD-10-CM Feedback: In ICD-10-CM‘s Alphabetic Index, you will see terms such as: Abscess Carcinoma Hyperemia Pneumonia Shock

Ulcer Learning Objective: 03.02 Topic: The Alphabetic Indexes Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 8. Answer: D HCPCS Level II Feedback: In HCPCS Level II‘s Alphabetic Index, you will see terms such as: Ambulance Commode IPPB machine Nebulizer Wheelchair Learning Objective: 03.02 Topic: The Alphabetic Indexes Blooms: Remember CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 9. Answer: B symbols, notations Feedback: The Main Section and Tabular List of the code books all contain additional symbols and notations to help you determine the most accurate code. Learning Objective: 03.02 Topic: The Alphabetic Indexes Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 10. Answer: C CPT Feedback: The Tabular list of the ICD-10-CM code book lists all of the codes in alphanumeric order.

The Main Section of the HCPCS Level II code book lists all of the codes in alphanumeric order. The Main Section of the CPT code book lists all of the codes in numeric order. The Tables of the ICD-10-PCS code book lists all of the codes in alphanumeric order. Learning Objective: 03.03 Topic: The Tabular List, Main Section, Tables, and Alphanumeric Section Blooms: Remember CAAHEP: IX.C.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 11. Answer: C cutaneous abscess of chest wall L02.213 Feedback: Cutaneous abscess of chest wall L02.213 is a full code description. L01.0, L02.22 and L02.23 all require an additional character – note the symbol beside each code reminding you that a 5th or 6th character is required. Learning Objective: 03.03 Topic: The Tabular List, Main Section, Tables, and Alphanumeric Section Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 12. Answer: A Use additional code to identify alcohol abuse and dependence Feedback: In the tabular list above code K70.31 there is a ―Use additional code‖ notation to identify alcohol abuse and dependence. Learning Objective: 03.03 Topic: The Tabular List, Main Section, Tables, and Alphanumeric Section Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 13. Answer: C the code is an add-on code Feedback: This symbol, plus sign, tells you, the coder, that the code is an add-on code and cannot be assigned independently. Learning Objective: 03.03 Topic: The Tabular List, Main Section, Tables, and Alphanumeric Section Blooms: Remember

CAAHEP: IX.C.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 14. Answer: D ICD-10-PCS Feedback: The majority of the codes suggested in the Alphabetic Index of ICD10-PCS are not complete codes. This forces the issue that you will have to go into the Tables Section to build the code out to seven (7) characters (based on the additional details in the operative notes). There is no way to report a complete, valid code without going into the Tables. NOTE: Even in those rare occasions when the Alphabetic Index provides you with all seven characters for the code, you still should go to the appropriate Table to confirm. It will only take a few seconds, and you can be certain you are reporting the complete and accurate code. Learning Objective: 03.03 Topic: The Tabular List, Main Section, Tables, and Alphanumeric Section Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 15. Answer: C 0NQV0ZZ Feedback: 0NQV0ZZ is the correct ICD-10-PCS code for the Repair of mandible, left side, open approach. Learning Objective: 03.03 Topic: The Tabular List, Main Section, Tables, and Alphanumeric Section Blooms: Remember CAAHEP: IX.P.1 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 16. Answer: B 43653 Feedback: 43653 is the correct code for a Laparoscopy, surgical; gastrostomy, without construction of gastric tube (e.g. Stamm procedure) Learning Objective: 03.03 Topic: The Tabular List, Main Section, Tables, and Alphanumeric Section Blooms: Remember

CAAHEP: IX.P.1 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 17. Answer: A guidelines Feedback: Coding is important work, so you want to get it accurate every time. To accomplish this, it is essential to have help and support exactly when you need it. And you have that help right at your fingertips within each code set's book. Always there, just the turn of a few pages, is the guidance from those who created these code sets and who oversee their legal and correct use. These are the published Official Guidelines with which you must comply. Official guidelines are a listing of rules and regulations instructing you how to use a specific code set accurately. You don't need to memorize them, you just need to remember they are there and refer to them every time you are working to determine a code. Learning Objective: 03.04 Topic: The Official Guidelines Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 18. Answer: D front of the code book Feedback: The official guidelines for ICD-10-CM can usually be found in the front of this code book entitled, ―ICD-10-CM Official Guidelines for Coding and Reporting‖. Learning Objective: 03.04 Topic: The Official Guidelines Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 19. Answer: C What Feedback: The code or codes that you report to identify the reasons why the patient required the attention of a health care professional justify what the

physician or health care professional did to the patient or for the patient… but only when they are in accordance with the standards of care. Learning Objective: 03.05 Topic: Confirming Medical Necessity Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 20. Answer: B Linking Feedback: Linking confirms medical necessity by pairing at least one diagnosis code to at least one procedure code Learning Objective: 03.05 Topic: Confirming Medical Necessity Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Guidelines Part I Answer: 1. D Section IV 2. B Section II 3. A Section I 4. C Section III Feedback: 1. D Section IV 2. B Section II 3. A Section I 4. C Section III Learning Objective: 03.04 Topic: The Official Guidelines Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Part II Answer: 1. I Section 1.B.10 2. A Section 1.A.2 3. C Section 1.A.6.b 4. D Section 1.A.13 5. E Section 1.A.17 6. G Section 1.B. 5 7. B Section 1.A.4 8. H Section 1.B.6 9. F Section 1.B.4 10. J Section 1.B.13 Feedback: 1. I Section 1.B.10 2. A Section 1.A.2 3. C Section 1.A.6.b 4. D Section 1.A.13 5. E Section 1.A.17 6. G Section 1.B. 5 7. B Section 1.A.4 8. H Section 1.B.6 9. F Section 1.B.4 10. J Section 1.B.13 Learning Objective: 03.04 Topic: The Official Guidelines Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minute Let’s Check It! Rules and Regulations 1. Answer: Action 1. Abstract the documentation.  Read completely through the physician‘s notes for the encounter, from beginning to end.  Then, reread the documentation and identify the key words regarding diagnoses (why) and procedures (what) directly related to the encounter.  Remember, if the patient is injured, you will need to identify the external causes (how and where), as well. Action 2. Query, if necessary  Make a list of any questions you have regarding unclear or missing information necessary to code the encounter. Query, or confer with, the

health care provider who cared for the patient. Never assume or try to guess. You are only allowed to code what you know from actual documentation. If it is not documented, it did not happen. If it didn’t happen, you cannot code it!  Create a query using non-leading questions, with open-ended or multiple option formatting, to have the physician amend the documentation, so you can use those added details to determine the accurate code or codes. NOTE: In school, your queries should go to your instructor. [smile] Action 3. Code the Diagnosis or Diagnoses  Code each diagnosis and/or appropriate signs or symptoms describing why the health care provider treated this patient during this encounter, as documented in the notes. Use the best, most accurate code available based on that documentation. Action 4. Code the Procedure or Procedures.  Determine for whom you are reporting: physician, outpatient facility, or inpatient facility. This way, you will know which code set to use: CPT or ICD-10-PCS.  Code each procedure, service, or treatment, as stated in the notes, describing what the provider did for the patient during this encounter. You should not code any procedures that are simply recommended, suggested, or ordered; only those that have already been provided to the patient for the encounter for which you are reporting. Use the best, most accurate codes available based on the documentation.  In some cases, you will also need to report a code or codes using the HCPCS Level II code set. More about this in Part 4 of this book. Action 5. Confirm Medical Necessity  Link each and every procedure code to at least one diagnosis code to verify medical necessity.  Remember, every encounter between patient and healthcare professional must have at least one diagnosis code and at least one procedure code. Action 6. Double-Check Your Codes You, as the professional coding specialist, have a responsibility to ensure that you are submitting only accurate, truthful information, supported by the physician‘s documentation. Yet, we are all human and anyone can make a mistake. Now is the time to build the habit of double-checking your work before you hit that submit button.  Go back into the code books you have used, and reread the full descriptions, as well as all notations and symbols of the codes you have assigned and match them back to the original documentation — one more time.  Read carefully, one letter at a time, one number at a time so you can catch and correct any typos before it all becomes official. Feedback: Action 1. Abstract the documentation.



Read completely through the physician‘s notes for the encounter, from beginning to end.  Then, reread the documentation and identify the key words regarding diagnoses (why) and procedures (what) directly related to the encounter.  Remember, if the patient is injured, you will need to identify the external causes (how and where), as well. Action 2. Query, if necessary  Make a list of any questions you have regarding unclear or missing information necessary to code the encounter. Query, or confer with, the health care provider who cared for the patient. Never assume or try to guess. You are only allowed to code what you know from actual documentation. If it is not documented, it did not happen. If it didn’t happen, you cannot code it!  Create a query using non-leading questions, with open-ended or multiple option formatting, to have the physician amend the documentation, so you can use those added details to determine the accurate code or codes. NOTE: In school, your queries should go to your instructor. [smile] Action 3. Code the Diagnosis or Diagnoses  Code each diagnosis and/or appropriate signs or symptoms describing why the health care provider treated this patient during this encounter, as documented in the notes. Use the best, most accurate code available based on that documentation. Action 4. Code the Procedure or Procedures.  Determine for whom you are reporting: physician, outpatient facility, or inpatient facility. This way, you will know which code set to use: CPT or ICD-10-PCS.  Code each procedure, service, or treatment, as stated in the notes, describing what the provider did for the patient during this encounter. You should not code any procedures that are simply recommended, suggested, or ordered; only those that have already been provided to the patient for the encounter for which you are reporting. Use the best, most accurate codes available based on the documentation.  In some cases, you will also need to report a code or codes using the HCPCS Level II code set. More about this in Part 4 of this book. Action 5. Confirm Medical Necessity  Link each and every procedure code to at least one diagnosis code to verify medical necessity.  Remember, every encounter between patient and healthcare professional must have at least one diagnosis code and at least one procedure code. Action 6. Double-Check Your Codes You, as the professional coding specialist, have a responsibility to ensure that you are submitting only accurate, truthful information, supported by the physician‘s documentation. Yet, we are all human and anyone can make a mistake. Now is the time to build the habit of double-checking your work before you hit that submit button.



Go back into the code books you have used, and reread the full descriptions, as well as all notations and symbols of the codes you have assigned and match them back to the original documentation — one more time.  Read carefully, one letter at a time, one number at a time so you can catch and correct any typos before it all becomes official. Learning Objective: 03.01 Topic: The Coding Process Overview Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 2. Answer: Now that you identified the key terms that describe the diagnosis and the procedure, the next action is to find the accurate code to report these details by matching those key terms to an entry in the Alphabetic Index. The Alphabetic Index lists all of the key terms that are represented by codes included in this code set, in alphabetic order (A to Z) by those words you abstracted from the documentation. Often, you will find that further details will be necessary, and options will be provided in another list, indented from the previous indented list. You are required to keep making choices, matching the documentation, all the way to the most specific detail. Once at the most specific level, you will see that the Alphabetic Index will suggest a code or codes. These codes are only suggestions and you are not done with the coding process yet. You are required to continue on, and find the suggested code in the Main Section or Tabular List or Tables of that code book. Feedback: Now that you identified the key terms that describe the diagnosis and the procedure, the next action is to find the accurate code to report these details by matching those key terms to an entry in the Alphabetic Index. The Alphabetic Index lists all of the key terms that are represented by codes included in this code set, in alphabetic order (A to Z) by those words you abstracted from the documentation. Often, you will find that further details will be necessary, and options will be provided in another list, indented from the previous indented list. You are required to keep making choices, matching the documentation, all the way to the most specific detail. Once at the most specific level, you will see that the Alphabetic Index will suggest a code or codes. These codes are only suggestions and you are not done with the coding process yet. You are required to continue on, and find the suggested code in the Main Section or Tabular List or Tables of that code book. Learning Objective: 03.02

Topic: The Alphabetic Indexes Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: The Alphabetic Index can only suggest a possible code to report the patient‘s diagnosis, and you will use this suggestion to guide you to the correct page or subsection in the Tabular List. You must always turn to this suggested code in the Tabular List, to confirm it is accurate, or to find another code that might be better. The Tabular List provides you with each and every available code in ICD-10CM, in order of the code characters – alphanumeric order: A00 through Z99.89. You need to carefully read the descriptions, beginning at the top of the subheading, so you can make certain that you find the best code, to the highest level of specificity, according to the physician‘s notes for a particular encounter and following the directions of the book. Feedback: The Alphabetic Index can only suggest a possible code to report the patient‘s diagnosis, and you will use this suggestion to guide you to the correct page or subsection in the Tabular List. You must always turn to this suggested code in the Tabular List, to confirm it is accurate, or to find another code that might be better. The Tabular List provides you with each and every available code in ICD-10CM, in order of the code characters – alphanumeric order: A00 through Z99.89. You need to carefully read the descriptions, beginning at the top of the subheading, so you can make certain that you find the best code, to the highest level of specificity, according to the physician‘s notes for a particular encounter and following the directions of the book. Learning Objective: 03.03 Topic: The Tabular List, Main Section, Tables, and Alphanumeric Section Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4.

Answer: The official guidelines are a listing of rules and regulations instructing how to use a specific code set accurately. With all these code sets and all these codes, you can see that the process to get from documentation-to-code is more complicated than simply finding a word here and a code there. This is important work, so you want to get it correctly – every time. To accomplish this, it is good to have help and support exactly when you need it. And you have that help, right at your fingertips, within each of these code set books. Always there, just a turn of a few pages away, is the guidance from those who created these code sets and oversee their legal and correct use. These are the published, official guidelines with which you must comply. Location of the official guidelines: ICD-10-CM - Usually in the front of this code book, you will find the section titled, ―ICD-10-CM Official Guidelines for Coding and Reporting‖. CPT - In the front of each individual main section, you will find the guidelines applicable to that part of the CPT codes. So, in front of the Evaluation and Management (E/M) Services codes are the pages containing the Evaluation and Management (E/M) Services Guidelines; in front of the Anesthesia code section are the Anesthesia Guidelines, etc. However, it is important to note that the CPT book also includes official guidelines within the sections, at some sub-sections, with advice and direction for accurate coding of just those procedures, services, and treatments. This means you must get in the habit of reading from the beginning of each section and the beginning of the sub-section before determining a code. It only takes a few seconds and it can make the difference between accuracy and fraudulent. ICD-10-PCS - Usually in the front of this codebook, you will find the section titled, ―ICD-10-PCS Official Guidelines for Coding and Reporting‖. Feedback: The official guidelines are a listing of rules and regulations instructing how to use a specific code set accurately. With all these code sets and all these codes, you can see that the process to get from documentation-to-code is more complicated than simply finding a word here and a code there. This is important work, so you want to get it correctly – every time. To accomplish this, it is good to have help and support exactly when you need it. And you have that help, right at your fingertips, within each of these code set books. Always there, just a turn of a few pages away, is the guidance from those who created these code sets and oversee their legal and correct use. These are the published, official guidelines with which you must comply. Location of the official guidelines: ICD-10-CM - Usually in the front of this code book, you will find the section titled, ―ICD-10-CM Official Guidelines for Coding and Reporting‖.

CPT - In the front of each individual main section, you will find the guidelines applicable to that part of the CPT codes. So, in front of the Evaluation and Management (E/M) Services codes are the pages containing the Evaluation and Management (E/M) Services Guidelines; in front of the Anesthesia code section are the Anesthesia Guidelines, etc. However, it is important to note that the CPT book also includes official guidelines within the sections, at some sub-sections, with advice and direction for accurate coding of just those procedures, services, and treatments. This means you must get in the habit of reading from the beginning of each section and the beginning of the sub-section before determining a code. It only takes a few seconds and it can make the difference between accuracy and fraudulent. ICD-10-PCS - Usually in the front of this codebook, you will find the section titled, ―ICD-10-PCS Official Guidelines for Coding and Reporting‖. Learning Objective: 03.04 Topic: The Official Guidelines Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: Linking is confirming medical necessity by pairing at least one diagnosis code to at least one procedure code. No one believes physicians or other health care professionals should be permitted to do whatever they want to a patient without a good valid reason. In our industry, this is known as medical necessity. The code or codes that you report to identify the reasons why the patient required the attention of a health care professional justify what the physician or health care professional did to the patient or for the patient… but only when they are in accordance with the standards of care. Once you have determined the accurate diagnosis codes and procedure codes, you must confirm that you are reporting at least one diagnosis code to identify medical necessity by linking it to at least one procedure code. You must take this action to ensure that the diagnosis codes you are reporting accurately represent the documented reasons why the physician made the decisions he or she made and provided care to this patient, based on those reasons. You must make certain you did not miss anything in the documentation. You must make certain you did not jot down, or enter, the code incorrectly [a typo?].

Feedback: Linking is confirming medical necessity by pairing at least one diagnosis code to at least one procedure code. No one believes physicians or other health care professionals should be permitted to do whatever they want to a patient without a good valid reason. In our industry, this is known as medical necessity. The code or codes that you report to identify the reasons why the patient required the attention of a health care professional justify what the physician or health care professional did to the patient or for the patient… but only when they are in accordance with the standards of care. Once you have determined the accurate diagnosis codes and procedure codes, you must confirm that you are reporting at least one diagnosis code to identify medical necessity by linking it to at least one procedure code. You must take this action to ensure that the diagnosis codes you are reporting accurately represent the documented reasons why the physician made the decisions he or she made and provided care to this patient, based on those reasons. You must make certain you did not miss anything in the documentation. You must make certain you did not jot down, or enter, the code incorrectly [a typo?]. Learning Objective: 03.05 Topic: Confirming Medical Necessity Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.2 CAAHEP: IX.C.3 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes Chapter 4: Medical Coding Fundamentals Capstone

2024 Compliant Learning Outcomes After completing this chapter, the student should be able to: LO 04.01 Apply the concepts learned, and correctly identify the most accurate practice to employ when faced with a professional coding process. Chapter Overview

The questions in this chapter will support student‘s learning and demonstrate the foundational knowledge of the concepts and building of skills needed to become a successful medical coding specialist. Remind them to read carefully and completely.

Additional Resources Grey’s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman’s Medical Dictionary: http://www.stedmans.com/ AAPC: http://www.aapc.com American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org

American Medical Association: http://www.ama-assn.org ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Question 1 CORRECT ANSWER: B FEEDBACK: Equipment and supplies provided to a patient are most often reported with codes from the HCPCS Level II code set.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 2 CORRECT ANSWER: D FEEDBACK: The first letter of every ICD-10-PCS code identifies the Section of ICD-10-PCS from which the procedure is reported

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Question 3 CORRECT ANSWER: C FEEDBACK: ICD-10-CM codes explain why healthcare services were provided.

Learning Objective: 04.01

Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Question 4 CORRECT ANSWER: A FEEDBACK: A confirmed diagnosis explains the patient‘s illness, injury, or other reason for healthcare services

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 5 CORRECT ANSWER: C FEEDBACK: When a medical coding specialist must report what services a physician provided to a patient, code from CPT must be reported, regardless of the location.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 6 CORRECT ANSWER: B FEEDBACK: A CPT code always has 5 numbers.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 7 CORRECT ANSWER: A FEEDBACK: An ICD-10-PCS code always has 7 alphanumeric characters.

Learning Objective: 04.01

Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Question 8 CORRECT ANSWER: D FEEDBACK: A HCPCS Level II code always has 1 letter followed by 4 numbers.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 9 CORRECT ANSWER: C FEEDBACK: An ICD-10-CM code always has 3 – 7 alphanumeric characters.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Question 10 CORRECT ANSWER: D FEEDBACK: Healthcare services provided in a physician‘s office is considered outpatient care.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 11 CORRECT ANSWER: A FEEDBACK: A note from a school nurse cannot be used by the medical coding specialist to justify a code or codes. The documentation must come from the attending physician.

Learning Objective: 04.01

Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Question 12 CORRECT ANSWER: D FEEDBACK: The medical coding specialist must understand medical terminology so the details in all documents written by clinicians can be accurately interpreted.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 13 CORRECT ANSWER: C FEEDBACK: The flu is known to cause fever and a cough, so these conditions are considered inclusive to the flu diagnosis and not coded separately.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 14 CORRECT ANSWER: B FEEDBACK: Two conditions found in one patient at the same time, which are not related to each other, are known as co-morbidities.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember

CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Question 15 CORRECT ANSWER: D FEEDBACK: A sequela is a condition that was directly caused by another condition which has been resolved.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 16 CORRECT ANSWER: B FEEDBACK: External cause codes are used to explain where the injury occurred, how it occurred, what the patient was doing at the time, and what the patient‘s status was at the time.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 17 CORRECT ANSWER: A FEEDBACK: A recommendation with advice or a second opinion is also reported with CPT codes. Tests, injections, and x-rays are included in procedures, services, and treatments.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 18 CORRECT ANSWER: C FEEDBACK: Interpreting is the process of converting the relevant words or phrases in healthcare documentation into medical codes.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Question 19 CORRECT ANSWER: B FEEDBACK: Code only the flu shot, which is happening at this encounter. The blister no longer requires the physician‘s attention or care.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 20 CORRECT ANSWER: C FEEDBACK: Every healthcare professional/patient encounter must have at least one reportable (codable) reason why and at least one reportable (codable) explanation of what.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Question 21 CORRECT ANSWER: B FEEDBACK: The sequence of actions required to interpret physician documentation into the codes that accurately report what occurred during a specific encounter between health care professional and patient, is known as the coding process.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Question 22

CORRECT ANSWER: D FEEDBACK: Confirming medical necessity by pairing at least one diagnosis code to at least one procedure code is known as linking

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 23 CORRECT ANSWER: A FEEDBACK: Alphanumeric means having both letters (alpha) and numbers (numeric).

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Question 24 CORRECT ANSWER: C FEEDBACK: The diagnosis codes report the medical necessity for the procedure codes.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 25 CORRECT ANSWER: B FEEDBACK: A listing of rules and regulations instructing how to use a specific code set accurately is known as the Official Guidelines.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Question 26

CORRECT ANSWER: D FEEDBACK: If the documentation contains contradictory, ambiguous, or is missing details necessary for the determination of a specific code, the medical coding specialist is required to query the provider who wrote the documentation for the required details.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 27 CORRECT ANSWER: C FEEDBACK: To report why the patient needed care from a healthcare professional, the medical coding specialist must use ICD-10-CM codes.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Question 28 CORRECT ANSWER: A FEEDBACK: To report what a physician did to or for a patient, the medical coding specialist must use CPT codes.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Question 29 CORRECT ANSWER: B FEEDBACK: After the cast on the patient‘s leg was applied, the patient was provided with a pair of crutches. To report the provision of the crutches, the medical coding specialist must use HCPCS Level II.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1

Level of Difficulty: 1 Easy Est Time: 0-1 minute Question 30 CORRECT ANSWER: D FEEDBACK: The last step in your personal coding process should always be to double-check your codes carefully.

Learning Objective: 04.01 Topic: Medical Coding Fundamentals Blooms: Remember CAAHEP: IX.C.5 ABHES: 3.c CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Chapter 5 Introduction to ICD-10-CM 2024 Compliant Learning Outcomes

LO 5.1 Explain the official conventions used in ICD-10-CM. LO 5.2 Translate the Official Guidelines and how they impact the way codes are reported. LO 5.3 Use the Alphabetic Index in ICD-10-CM properly. LO 5.4 Employ the information within the Tabular List to determine the accurate code to report. LO 5.5 Distinguish which conditions mentioned in the documentation to report. LO 5.6 Utilize what you learned in this chapter to determine the correct diagnosis code to report. Chapter Outline Learning Outcomes Key Terms Introduction and Official Conventions Introduction ICD-10-CM Official Conventions Punctuation

Brackets Italicized or Slanted Brackets Parentheses Colon Abbreviations NEC NOS General Notes Includes, Excludes1, and Excludes 2 Code First Use Additional Code Code Also Category Notes

And With Other Specified Unspecified See See Also See Condition Additional Characters Required Box with a Checkmark and Number Hyphen ICD-10-CM Official Guidelines for Coding and Reporting Section 1. Conventions, General Coding Guidelines and Chapter-Specific Guidelines Section 1.A. Conventions for the ICD-10-CM and Section 1.B. General Coding Guidelines Multiple and Additional Codes Acute and Chronic Conditions Combination Codes Two or More Conditions – Only One Confirmed Diagnosis Differential Diagnosis Other Current Conditions Placeholder Character Seventh Character Section 1. C. Chapter-Specific Coding Guidelines Section II. Selection of Principal Diagnosis and Section III. Reporting Additional Diagnoses

Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services Unconfirmed Diagnoses Outpatient Services Inpatient Services Appendix I. Present-On-Admission Reporting Guidelines The Alphabetic Index and Ancillaries Index to Diseases and Injuries (aka Alphabetic Index) Neoplasm Table Table of Drugs and Chemicals Index to External Causes The Tabular List Tabular List Chapter Heads The Legends Using the Tabular List Which Conditions to Code Unrelated Conditions Systemic Conditions Screenings and Other Preventive Services Test Results Preoperative Evaluations Preoperative/Postoperative Diagnoses Putting It All Together: ICD-10-CM Basics Chapter Summary Chapter 5 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Practice You Code It! Application

Chapter Overview For the second layer of your learning, you will focus on interpreting and reporting the key terms and details about the diagnoses, signs, and symptoms—the reasons why the physician provided care to the patient during a specific encounter. As you learned in Part I of this book, this is known as medical necessity. The concept of medical necessity is as simple as it sounds—the determination that a medical procedure, service, or treatment needed to be provided to a patient because of an identified health care issue or concern. Overall, the industry uses the accepted standards of care by which to measure the rationale—the justification—for every action taken on behalf of an individual patient. For example, atrial fibrillation [irregular heart beats in the upper chambers of the heart] may be a diagnosis that supports the insertion of a pacemaker; however, ventricular fibrillation [irregular heart beats in the lower chambers of the

heart] does not. A diagnosis of dysphasia [problems with speech] justifies the provision of a speech evaluation; however, a diagnosis of dysphagia *problems with swallowing+ does not. The physician’s confirmation of a hydrocele [collection of fluid in tunica vaginalis, spermatic cord, or testis] can only be diagnosed in a male patient and the determination of a hematometra [accumulated blood in the uterus] can only be diagnosed in a female. When you think about it—why would anyone pay for, or accept, the provision of medical treatment to patients who do not need treatment? The way you will explain that the physician’s actions were reasonable and correct is by reporting the accurate diagnosis code or codes. Discussion Activities 1. Discuss the four different sections of the Official Coding Guidelines and how you would use them to support accurate coding. Learning Outcome: 5.2 Section 1. Conventions, General Coding Guidelines and Chapter-Specific Guidelines Section II. Selection of Principal Diagnosis Section III. Reporting Additional Diagnoses Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services Optional to include in the discussion…. Appendix I. Present-On-Admission Reporting Guidelines

2. Discuss specific examples of the impact of inaccurate coding on: - the patient - the physician and the facility Learning Outcome: 5.4 and 5.6 Some examples that you can cover in your class discussion: The patient may not be able to get the health services they need because the insurance carrier denied the claim due to inaccurate codes. The patient may have to pay for a procedure or service out of pocket, over and above their insurance premiums, when the insurance company should have paid for the procedure but won’t because the codes are not correct. The patient may have difficulty getting health insurance in the future because his or her chart states a condition this person never had. For example, John goes to get a test to rule out HIV. If the coder reported that John was HIV positive, this might cause John unfair problems with health care treatment and coverage in the future.

The physician’s reimbursement, as well as that for the facility, may be negatively impacted. When a claim for a procedure that was provided is denied because the diagnosis code shown did not support medical necessity means that the physician or the facility (or both) does not get the money he or she rightfully earned by providing the procedure or service. Consistent errors in coding may result in fines, penalties, and prison if found to be fraudulent behavior (Human errors are expected to be corrected over time. When the same mistake keeps happening, there is reason to suspect fraud). When a claim is improperly denied, the physician must spend money and additional staff time to appeal the denial. In addition, the physician (and the facility) must deal with not having the money, reducing the funds available for payroll, rent, utilities, equipment, etc.

3. What code or codes would you report?

Learning Outcome: 5.6 Read this scenario then determine what diagnosis code or codes you would use. Explain why you chose this code(s). PATIENT: Newman, Oscar ACCOUNT/EHR #: NEWOS001 DATE: 11/21/18 ATTENDING PHYSICIAN: Phillip Jackman, MD SUBJECTIVE: The patient is a 33-year-old male, who comes complaining of bilateral ear discomfort, right greater than left. He has been having it intermittently for about a week or two and he said it is worse at night, better in the daytime. He reports no discharge from ears, and has no history except, three years ago, of having a right tympanic membrane perforation that healed spontaneously. He denies buzzing, no loss of hearing, no blocked sensation of the ear. He had been swimming recently, and he was concerned about an infection that may have been picked up while swimming. No other recent travel or sick contacts. He denies fevers, chills, nausea, vomiting, or sweats. No headaches or visual disturbances. No sinus pain or pressure. No temporomandibular joint symptoms. No teeth grinding symptoms. He has some mild tender neck glands, particularly on the right. No sore throat. No postnasal drip and no cough. No shortness of breath. No wheezing. He is otherwise feeling well. OBJECTIVE: On examination, the patient is a well-developed, well-nourished male, in no acute distress. His blood pressure is 125/90 with a pulse of 64. Temperature is 98.6. His pupils are equal, round, and reactive to light. Extraocular muscles are intact. There is no tenderness to opening and closing of the jaw at the temporomandibular joint. There is minimal discomfort to tugging on the pinna on either side. The tragus is nontender on either side. Canals are clear. Tympanic membranes are with good light reflex. There is no retraction. There is no bulging of the drum. There is no fluid seen behind the tympanic membranes. There is no debris or discharge noted in canals. There is no wax. The neck is supple. No cervical lymphadenopathy. There is no frontal maxillary sinus tenderness noted. He has good range of motion of the head about the neck and flexion-extension, side-to-side rotation. Lungs are clear to auscultation, and heart exam shows normal S1, S2, no murmurs appreciated. Peripheral pulses are intact. No other oral lesions are noted, minimal injection of posterior pharynx only. ASSESSMENT AND PLAN: Overall impression is bilateral otalgia with a normal exam. There was no sign of any infection. We have reassured him that at this point in time things look good. If things get worse, he is instructed to call our office. Right now, the exam is quite normal and no antibiotic is needed at this time. Follow up as needed. Answer: H92.03 Otalgia, bilateral This seems pretty straightforward, and it is. However, you still must be diligent and read all of the documentation completely and carefully to be certain. The patient came in complaining of pain in his ears. Otalgia is the medical term for ear pain [ot = ear + algia = pain] In this case, you could go into the Alphabetic Index and look up: Pain(s) > ear – see subcategory H92.0Or you can look up: Otalgia H92.0-

Additional Resources Grey’s Anatomy Online: http://www.bartleby.com/107/ Stedman’s Medical Dictionary: http://www.stedmans.com/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html American Medical Association: http://www.ama-assn.org

American Hospital Association: http://www.aha.org American Health Information Management Association: http://www.ahima.org AAPC: http://www.aapc.com

ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm

CHAPTER 5 REVIEW ANSWER KEY Let‘s Check It! Terminology Part I Answer: 1. E Tabular List of Diseases and Injuries 2. A Alphabetic Index 3. D Table of Drugs and Chemicals 4. C Neoplasm Table 5. B Index to External Causes Learning Objective: 05.03 Learning Objective: 05.04 Topic: The Alphabetic Index and Ancillaries Topic: The Tabular List Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part II Answer: 1. B Anatomical Site 2. D Confirmed 3. E Eponym 4. J Systemic Condition 5. G Inpatient Facility 6. I Sequela (Late Effect) 7. H Outpatient Services 8. C Condition 9. A Adverse Effect 10. F External Cause Learning Objective: 05.01 Learning Objective: 05.02 Learning Objective: 05.03 Learning Objective: 05.05 Topic: Introduction and Official Conventions

Topic: ICD-10-CM Official Guidelines for Coding and Reporting Topic: The Alphabetic Index and Ancillaries Topic: Which Conditions to Code Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part III Answer: 1. E Nonessential Modifier 2. F Not Elsewhere Classifiable (NEC) 3. B Chronic 4. D Manifestation 5. J Underlying Condition 6. K Unspecified 7. H Other Specified 8. I Principal Diagnosis 9. G Not Otherwise Specified (NOS) 10. A Acute 11. C Differential Diagnosis Learning Objective: 05.01 Learning Objective: 05.02 Topic: Introduction and Official Conventions Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts 1. Answer: C

K00-K95

Feedback: Chapter Code Range 1 A00–B99 2 C00–D49

Title Certain infectious and parasitic diseases Neoplasms

3

Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism 4 E00–E89 Endocrine, nutritional, and metabolic diseases 5 F01–F99 Mental, behavioral, and neurodevelopmental disorders 6 G00–G99 Diseases of the nervous system 7 H00–H59 Diseases of the eye and adnexa 8 H60–H95 Diseases of the ear and mastoid process 9 I00–I99 Diseases of the circulatory system 10 J00–J99 Diseases of the respiratory system 11 K00–K95 Diseases of the digestive system 12 L00–L99 Diseases of the skin and subcutaneous tissue 13 M00–M99 Diseases of the musculoskeletal system and connective tissue 14 N00–N99 Diseases of the genitourinary system 15 O00–O99 Pregnancy, childbirth, and the puerperium + O9A 16 P00–P96 Certain conditions originating in the perinatal period 17 Q00–Q99 Congenital malformations, deformations, and chromosomal abnormalities 18 R00–R99 Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified 19 S00–T88 Injury, poisoning, and certain other consequences of external causes 20 V00–Y99 External causes of morbidity 21 Z00–Z99 Factors influencing health status and contact with health services Learning Objective: 05.04 Topic: The Tabular List Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer:

D50–D89

D organic

Feedback: The nonessential modifiers listed for Hypertension in the ICD-10-CM Alphabetic index, are accelerate, benign, essential, idiopathic, malignant, systemic. Learning Objective: 05.01 Topic: Introduction and Official Conventions

Blooms: Understand CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 3. Answer:

B

Selection of Principal Diagnosis

Feedback: The ICD-10-CM Official Guidelines section titles and numbers are: Section I= Conventions, general coding guidelines and chapter specific guidelines Section II= Selection of Principal Diagnosis Section III= Reporting Additional Diagnoses Section IV= Diagnostic Coding and Reporting Guidelines for Outpatient Services Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 4. Answer: C ―See‖ and ―See Also‖ Feedback: The ICD-10-CM Official Guidelines I.A.16 are guidelines with instructions concerning the word(s) ―See‖ and ―See Also.‖ Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 5. Answer: B

must be included

Feedback: [ ] Italicized, or slanted, brackets, used in the Alphabetic Index, will surround an additional code or codes (i.e., secondary codes) that must be included with the

initial code. It is the Alphabetic Index‘s version of the code first and use additional code notations. Learning Objective: 05.01 Topic: Introduction and Official Conventions Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 6. Answer: C

the ICD-10-CM book didn‘t provide a code with more details

Feedback: NEC Not elsewhere classifiable (NEC), or not elsewhere classified, indicates that the physician provided additional details of the condition but the ICD-10-CM book did not include those extra details in any of the other codes in the book. Learning Objective: 05.01 Topic: Introduction and Official Conventions Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 7. Answer: D

a wound

Feedback: A condition is the state of abnormality or dysfunction. Examples of a condition is infections, fractures, and wounds. Learning Objective: 05.03 Topic: The Alphabetic Index and Ancillaries Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 8. Answer:

C J96.21

Feedback: J96.21: ICD-10-CM index>failure>respiratory>acute and (on) chronic>with>hypoxia J96.21 Acute and chronic respiratory failure with hypoxia

Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Understand CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 9. Answer: B sprain of left corahumeral Feedback: If a patient has a systemic condition, this means that this condition affects the entire body, for example, diabetes mellitus, hypertension, or pregnancy. The physician, therefore, must take this into consideration in the medical decision-making for virtually any other condition.

Learning Objective: 05.05 Topic: Which Conditions to Code Blooms: Remember CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 10. Answer: A Z02.1

Feedback: Z02.1 is the correct code for a pre-employment examination Z02.1: Index>examination>medical>pre-employment Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Understand CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute Let‘s Check It! Guidelines 1. Answer: Alphabetic, Tabular Feedback: I.A.1

The ICD-10-CM is divided into the Alphabetic Index, an alphabetical list of terms and their corresponding code, and the Tabular List, a structured list of codes divided into chapters based on body system or condition. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 2. Answer: Diseases, Drugs Feedback: I.A.1 The Alphabetic Index consists of the following parts: the Index of Diseases and Injury, the Index of External Causes of Injury, the Table of Neoplasms and the Table of Drugs and Chemicals. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 3. Answer: 3 Feedback: I.A.2 All categories are 3 characters. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 4. Answer: invalid Feedback: I.A.2

A code that has an applicable seventh character is considered invalid without the seventh character. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 5. Answer: placeholder Feedback: I.A.4 The ―X‖ is used as a placeholder at certain codes to allow for future expansion. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 6. Answer: unspecified, insufficient Feedback: I.A.9.b Codes titled unspecified are for use when the information in the medical record is insufficient to assign a more specific code. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 7. Answer: Excludes1 Feedback: I.A.12.a A type 1 Excludes note is a pure excludes note. It means ―NOT CODED HERE!‖ Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting

Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 8. Answer: Excludes2 Feedback: I.A.12.b A type 2 Excludes note represents ―Not included here‖. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 9. Answer: first, verify Feedback: I.B.1 To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, first locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: reported, highest Feedback: I.B.2 Diagnosis codes are to be used and reported at their highest number of characters available. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 11. Answer: related, not, established Feedback: I.B.4 Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 12. Answer: separate, same, both, acute Feedback: I.B.8 If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute code first. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 13. Answer: once Feedback: I.B.12 Each unique ICD-10-CM diagnosis code may be reported only once for an encounter. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 14. Answer: left, right Feedback: I.B.13 If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 15. Answer: discharged, confirmed Feedback: I.B.17 If the provider documents a "borderline" diagnosis at the time of discharge, the diagnosis is coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes). Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute Let’s Check It! Rules and Regulations 1. Answer: When coding outpatient services, you must be certain that the patient‘s file verifies that the patient actually has the condition, disease, illness, or injury. The guideline (Section IV. I. Uncertain diagnosis) states that you are to use the code or codes that identify the condition to its highest level of certainty. This means that you code only what you know for a fact. You are not permitted to assign an ICD-10-CM diagnosis code for a condition that is described by the provider as probably, suspected, possible, questionable, or to be ruled out.

When coding inpatient facilities, you are directed by the guideline (Section II, H. Uncertain diagnosis), when at the time of discharge, the diagnosis is described as probable, possible, suspected, likely, or still to be ruled out, you must code that condition as if it did exist. This directive applies only when you are coding services provided in a short-term, acute, long-term care, or psychiatric hospital or facility. Feedback: When coding outpatient services, you must be certain that the patient‘s file verifies that the patient actually has the condition, disease, illness, or injury. The guideline (Section IV. I. Uncertain diagnosis) states that you are to use the code or codes that identify the condition to its highest level of certainty. This means that you code only what you know for a fact. You are not permitted to assign an ICD-10-CM diagnosis code for a condition that is described by the provider as probably, suspected, possible, questionable, or to be ruled out. When coding inpatient facilities, you are directed by the guideline (Section II, H. Uncertain diagnosis), when at the time of discharge, the diagnosis is described as probable, possible, suspected, likely, or still to be ruled out, you must code that condition as if it did exist. This directive applies only when you are coding services provided in a short-term, acute, long-term care, or psychiatric hospital or facility. Learning Objective: 05.02 Topic: ICD-10-CM Official Guidelines for Coding and Reporting Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: Never, never, never code only from the Alphabetic Index. You are required to check every code in the Tabular List. Only then can you read the entire code description and all notations to determine the most accurate code. Feedback: Never, never, never code only from the Alphabetic Index. You are required to check every code in the Tabular List. Only then can you read the entire code description and all notations to determine the most accurate code. Learning Objective: 05.03 Topic: The Alphabetic Index and Ancillaries Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes

3. Answer: The code first notation is a reminder that you are going to need another code to identify the underlying disease that caused this condition. This notation is also telling you in what order to report the two codes: the underlying condition first, followed by the code for the manifestation. Often, the notation will offer you a reference to the most common underlying diseases along with their codes. Feedback: The code first notation is a reminder that you are going to need another code to identify the underlying disease that caused this condition. This notation is also telling you in what order to report the two codes: the underlying condition first, followed by the code for the manifestation. Often, the notation will offer you a reference to the most common underlying diseases along with their codes. Learning Objective: 05.01 Topic: Introduction and Official Conventions Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: The Tabular List section of the ICD-10-CM book lists all the codes, and their complete descriptions, in alphanumeric order, by the code itself. Starting at A00, the codes go all the way through to Z99.89. You should never report a code directly from the Alphabetic Index without looking in the Tabular List. So, take the code that the Alphabetic Index suggested and find it in the Tabular List. Once in the Tabular List section or subsection, you will need to carefully read the complete code descriptions, beginning at the top of the subheading, so you can make certain that you have all the details you need to determine: the best code; to the highest level of specificity; according to the physician‘s notes for a particular encounter and in compliance with the rules and guidelines. Each of the chapters within the ICD-10-CM Tabular List focuses on conditions affecting the various body and organ systems or disease characteristics. Many of the 21 chapters within the Tabular List start out with valuable information that will support your determination of the accurate code to report. Across the bottom of every page throughout the Tabular List you will find short explanations for many of the symbols you will see amongst the codes and their descriptions. These are abbreviated from the more complete explanations of each symbol in the front of your code book, on the pages titled, "Overview of ICD-10-CM Official Conventions" and "Additional Conventions". The ICD-10-CM code book will lead you, step-by-step, to the correct, complete code. However, not all diagnostic statements follow a straight line. Sometimes, you have to

really read carefully and use your critical thinking skills to figure out what the problem really is. Other times, you may have to use alternate terms from those used in the notes to determine the correct code description. Feedback: The Tabular List section of the ICD-10-CM book lists all the codes, and their complete descriptions, in alphanumeric order, by the code itself. Starting at A00, the codes go all the way through to Z99.89 You should never report a code directly from the Alphabetic Index without looking in the Tabular List. So, take the code that the Alphabetic Index suggested and find it in the Tabular List. Once in the Tabular List section or subsection, you will need to carefully read the complete code descriptions, beginning at the top of the subheading, so you can make certain that you have all the details you need to determine: the best code; to the highest level of specificity; according to the physician‘s notes for a particular encounter and in compliance with the rules and guidelines. Each of the chapters within the ICD-10-CM Tabular List focuses on conditions affecting the various body and organ systems or disease characteristics. Many of the 21 chapters within the Tabular List start out with valuable information that will support your determination of the accurate code to report. Across the bottom of every page throughout the Tabular List you will find short explanations for many of the symbols you will see amongst the codes and their descriptions. These are abbreviated from the more complete explanations of each symbol in the front of your code book, on the pages titled, "Overview of ICD-10-CM Official Conventions" and "Additional Conventions". The ICD-10-CM code book will lead you, step-by-step, to the correct, complete code. However, not all diagnostic statements follow a straight line. Sometimes, you have to really read carefully and use your critical thinking skills to figure out what the problem really is. Other times, you may have to use alternate terms from those used in the notes to determine the correct code description. Learning Objective: 05.04 Topic: The Tabular List Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: Procedure and operative reporting usually include both a preoperative diagnosis and a postoperative diagnosis. For cases where the two statements differ, the guidelines state that you should code the postoperative diagnosis because it is expected that it is the more accurate of the two. Feedback: Procedure and operative reporting usually include both a preoperative diagnosis and a postoperative diagnosis. For cases where the two statements

differ, the guidelines state that you should code the postoperative diagnosis because it is expected that it is the more accurate of the two. Learning Objective: 05.05 Topic: Which Conditions to Code Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Basics 1. Answer: cystitis, N30.00 Feedback: Acute cystitis without hematuria: cystitis, N30.00 N30.00: Index>Cystitis>acute>without hematuria Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 2. Answer: necrosis, J85.0 Feedback: Pulmonary necrosis: necrosis, J85.0 J85.0: Index>Necrosis>pulmonary Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: fibrocystic, E84.9 Feedback: Fibrocystic disease pancreas: fibrocystic, E84.9 E84.9: Index>Fibrocystic>disease>pancreas Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 4. Answer: headache, R51.9 Feedback: Chronic daily headache: headache, R51.9 R51: Index>Headache> daily>chronic Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 5. Answer: inflammation, M27.2 Feedback: Inflammation of the jaw: inflammation, M27.2 M27.2: Index>Inflammation>jaw Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 6. Answer: mobile, N28.89 Feedback: Mobile kidney: mobile, N28.89 N28.89: Index>Mobile>kidney Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 7. Answer: pneumonia, J84.2 Feedback: Lymphoid interstitial pneumonia: pneumonia, J84.2

J84.2: Index>Pneumonia>interstitial>lymphoid Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 8. Answer: Fibrosis, E27.8 Feedback: Adrenal fibrosis: Fibrosis, E27.8 E27.8: Index>Fibrosis>adrenal Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 9. Answer: Infection, J39.8 Feedback: Upper respiratory infection, chronic: Infection, J39.8 J39.8: Index>Infection>respiratory>upper>chronic Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 10. Answer: Conjunctivitis, H10.31 Feedback: Acute conjunctivitis, right: Conjunctivitis, H10.31 H10.31a; Index>Conjunctivitis>acute>right Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy

Est Time: 3-5 minutes 11. Answer: Ulcer, L97.223 Feedback: Ulcer of lower limb, left calf with muscle necrosis: Ulcer, L97.223 L97.223: Index>Ulcer>lower limb>calf>left>with>muscle necrosis> Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 12. Answer: Endocarditis, I35.8 Feedback: Aortic endocarditis: Endocarditis, I35.8 I35.8: Index>Endocarditis>aortic Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 13. Answer: Cystitis, A18.12 Feedback: Tuberculous cystitis: Cystitis, A18.12 A18.12: Index>Cystitis>tuberculous Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 14. Answer: Appendicitis, K35.80 Feedback: Acute appendicitis: Appendicitis, K35.80 K35.80: Index>Appendicitis>acute Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics

Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 15. Answer: Lupus, M32.13 Feedback: Systemic lupus erythematosus with lung involvement: Lupus, M32.13 M32.13: Index>Lupus> erythematosus>systemic>with organ or system involvement>lung Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes YOU CODE IT! Practice 1. Answer: Z23 Feedback: Z23: Index>Vaccination>encounter for Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: Z22.322 Feedback: Z22.322: Index>Carrier>bacterial>staphylococcal>methicillin resistant Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium

Est Time: 3-5 minutes 3. Answer: I10 Feedback: I10: Index>Hypertension Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: C68.1 Feedback: C68.1: Neoplasm table>Skene‘s gland>malignant primary Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: Z60.0 Feedback: Z60.0: Index>Problem>adjustment>retirement Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: R06.4 Feedback: R06.4: Index>Hyperventilation Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: L56.8 Feedback: L56.8: Index>Dermatitis>radiation>sun>acute Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: A17.0 Feedback: A17.0: Index>Meningitis>tuberculous Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: B65.9, N29 Feedback: B65.9: Index>Disorder>kidney>in>schistosomiasis>unspecified N29: Index>Disorder>kidney>in>schistosomiasis>unspecified Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: I20.1 Feedback: I20.1: Index>Angina>with documented spasm Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: L29.0 Feedback: L29.0: Index>Pruritus> ani, anus Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 12. Answer: J01.20, B95.8 Feedback: J01.20: Index>Sinusitis>ethmoidal>acute B95.8: Index>Infection>staphylococcus>as cause of disease classified elsewhere Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: T18.120A Feedback: T18.120A: Index>Foreign body>esophagus>causing>tracheal compression>food (bone)>initial encounter Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14.

Answer: K05.01 Feedback: K05.01: Index>Gingivitis>acute>non-plaque induced Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: E73.0 Feedback: E73.0: Index>Deficiency>lactase>congenital Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application Application 1: Kassandra, Kelly Answer: J02.9 Feedback: J02.9: Index>Pharyngitis (acute) Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: Helen Davis Answer: N39.0, B95.8, K57.32 Feedback: N39.0: Index>Infection>urinary B95.8: Index>Infection>Staphylococcus>as cause of disease classified elsewhere K57.32: Index>Diverticulitis>intestine>large Learning Objective: 05.06

Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: Chantel Hobarth Answer: Z85.51 Feedback: Z85.51: Index>History>personal>malignant neoplasm>bladder Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: Joseph Romano Answer: S61.210A Feedback: S61.210A: Index>Laceration>finger>index>right>initial encounter Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: Vincent Flora Answer: S06.0X1A: Feedback: S06.0X1A: Index>Concussion>initial encounter (In the tabular list under S06.0X you will see a specific code for a concussion with loss of consciousness of 30 minutes or less) Learning Objective: 05.06 Topic: Putting It All Together: ICD-10-CM Basics Blooms: Apply CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

Chapter 6 Coding Infectious Diseases 2024 Compliant Learning Outcomes

LO 6.1 Interpret the details required to report an accurate code for an infection. LO 6.2 Clarify the details about bacterial infections. LO 6.3 Determine the specifics needed to report viral infections. LO 6.4 Translate information about parasitic and fungal infections into diagnosis codes. LO 6.5 Abstract documentation to identify important details about the specific pathogen causing a diagnosis. LO 6.6 Ascertain the correct code or codes to report immunodeficiency conditions. LO 6.7 Apply the guidelines for reporting blood infections. LO 6.8 Analyze the documentation to identify the code or codes required to report antimicrobial resistance.

Chapter Outline Learning Outcomes Key Terms Infectious and Communicable Diseases Infections and Inflammation Communicable Diseases Reporting the Infectious Agent Bacterial Infections Types of Bacteria Conditions Caused by Bacteria Impetigo Foodborne Illness Cellulitis Tetanus (Lockjaw) Tuberculosis

Viral Infections Types of Viruses Conditions Caused by Viruses Viral Warts Viral Hepatitis Viral Hepatitis, Type A Viral Hepatitis, Type B Viral Hepatitis, Type C Viral Hepatitis, Type D Viral Hepatitis, Type E Influenza Varicella Rubeola Rubella Herpes Simplex Virus Herpes Zoster Zika Virus Infections Parasitic and Fungal Infections Parasitic Infestations Fungal Infections Infections Caused by Several Pathogens Pneumonia Types of Pneumonia Bacterial Pneumonia Viral Pneumonia Fungal Pneumonia Secondary Pneumonia Meningitis Immunodeficiency Conditions Human Immunodeficiency Virus Infections Coding HIV Testing, Test Results, and Symptoms Test Negative Test Inconclusive Test Positive but Asymptomatic Test Positive with Symptoms or Manifestations HIV Status with Unrelated Conditions HIV Status in Obstetrics

Septicemia and Other Blood Infections Septicemia Sepsis Severe Sepsis Septic Shock Sepsis and Septic Shock Relating to Pregnancy or Newborns Sepsis during Labor Puerperal Sepsis Neonatal Sepsis Septic Condition Resulting from Surgery Systemic Inflammatory Response Syndrome Without Infection Antimicrobial Resistance Coding for AMR Clostridium difficile (C.diff) Carbapenem-Resistant Enterobacteriaceae (CRE) Neisseria gonorrhoeae Bacterial Infections Methicillin-Resistant Staphylococcus Aureus Infection Combination Codes Methicillin-Resistant Staphylococcus Aureus Colonization Chapter Summary Chapter 6 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application

Chapter Overview Many conditions and illnesses are spread from one individual to another. Infectious diseases are spread by physical contact, such as a handshake or the exchange of bodily fluids; others can be spread by the touch of a doorknob that has been handled by someone else. Your students may have heard about some of these conditions—such as meningitis, tuberculosis, and human immunodeficiency virus, more commonly known as HIV.

As coding specialists, your students’ vulnerability to these and other infectious diseases and conditions is limited. However, they should realize that protecting their health is the basis of certain safety protocols, such as wearing gloves and using special waste receptacles. As long as they follow these important policies, there is no reason for them to be afraid.

Discussion Activities 1.

Discuss the different types of infectious diseases. [Learning Outcome: 6.1]

Have students discuss the various types of infectious diseases, such as influenza, tuberculosis, and sexually transmitted diseases. Also, review the signs and symptoms for each disease, as well as standard diagnostic tests.

2.

Identify the coding guidelines as they relate to methicillin-resistant Staphylococcus aureus (MRSA) conditions. [Learning Outcome: 6.8]

The many media articles regarding MRSA can support a great deal of discussion about this type of infection, including signs and symptoms and diagnostic tests. Up-to-date information can be accessed at http://www.medicinenet.com/mrsa_infection/article.htm including a slide show.

3.

Explain the differences between bacterial, viral, and parasitic conditions. Include an example with its specific code. [Learning Outcome: 6.2, 6.3, 6.4]

Bacterial conditions include E. coli, H. influenza, and C. perfringens. Viral conditions include adenovirus, enterovirus, and parvovirus. Parasitic conditions include scarabiasis, scabies, and pediculosis due to Pediculus humanus capitis (head lice).

Additional Resources Infectious Disease Articles (eMedicine): http://emedicine.medscape.com/infectious_diseases Infectious Diseases/Communicable Diseases (MedlinePlus): http://www.nlm.nih.gov/medlineplus/infectiousdiseases.html Infectious Disease Center (MedicineNet): http://www.medicinenet.com/infectious_disease/focus.htm Infectious Diseases (Mayo Clinic): http://www.mayoclinic.com/health/infectious-diseases/DS01145 Hospital-Acquired Infections—A Serious Threat to ICU Patients (MedlinePlus): http://www.nlm.nih.gov/medlineplus/news/fullstory_106123.html Sexually Transmitted Diseases (MedlinePlus): http://www.nlm.nih.gov/medlineplus/sexuallytransmitteddiseases.html Grey’s Anatomy Online: http://www.bartleby.com/107/ Stedman’s Medical Dictionary: http://www.stedmans.com/

MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html American Medical Association: http://www.ama-assn.org American Hospital Association: http://www.aha.org American Health Information Management Association: http://www.ahima.org AAPC: http://www.aapc.com

ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm COVID-19 In 2020, the world experienced something not seen in 100 years… a global pandemic. We all got to become familiar with an infection due to SARS-CoV-2 virus, the 2019 novel coronavirus disease, known more commonly as COVID-19. This event has initiated the creation of new codes, and a new Chapter in the ICD-10-CM coding manual, Chapter 22. Codes for Special Purposes (U00-U85). EXPOSURE If a patient has been exposed to COVID-19, and is showing no signs or symptoms (asymptomatic), you will report the reason for this encounter with code: Z20.828 Contact with and (suspected) exposure to other viral communicable diseases EXHIBITING SIGNS AND SYMPTOMS If the patient is reporting signs and symptoms, and, there is no confirmed diagnosis yet, you need to report the codes for those specific signs and symptoms, for example: R06.02 Shortness of breath R50.9 Fever, unspecified When the documentation also states that the patient was exposed to COVID-19, report Z20.828, as well. CONFIRMED DIAGNOSIS Should the test come back positive, you will see a confirmed diagnosis of COVID-19 in the physician’s documentation. Then, you need to report this with: U07.1 COVID-19 There are cases when some patients, confirmed to have COVID-19 positive, also exhibit manifestations – other conditions caused by this infection. When these are documented, report the COVID-19 code U07.1 first, followed by the codes reporting the specific manifestation(s). LET’S CODE IT! SCENARIO Lillie Karnowski, a 25-year-old female, was admitted with acute bronchitis. She tested positive for COVID-19 last week after spending the weekend at the beach with her friends. Dr. Mancuso admits her with COVID-19-related acute bronchitis Let’s Code It! Lillie has been confirmed for COVID-19 and has now developed acute bronchitis as a result. The Official Coding Guidelines direct us to report the COVID-19 diagnosis first. Let’s turn in the Alphabetic Index to: Coronavirus (infection) Coronavirus-19 U07.1 COVID-19 U07.1 SARS-associated B97.21 This is straightforward. The thing to remember here is that the Chapter in the coding manual for the new U codes is not in alphabetic order like the rest, it is after the Z code chapter at the very end of the coding manual. U07.1 COVID-19

Read carefully. There is a Use additional code note, which confirm what the Official Guideline states… this code must be reported first, followed by the code for Lillie’s acute bronchitis. Also, there is an EXCLUDES1 notation with three conditions shown. Do any of these apply to this one case? No. Good, so you can report this code with confidence. Next, you need to report Lillie’s diagnosis of acute bronchitis. Let’s go back to the Alphabetic Index and find bronchitis. Read the list below this main term and find acute. Acute or subacute (with bronchospasm or obstruction) J20.9 There was no mention in the scenario about bronchospasms or obstruction, so let’s keep reading. A little further down the column, see Acute or subacute Viral NEC J20.8 Well, this fits! The documentation states the bronchitis was caused by the coronavirus. Turn to the Tabular list and find J20 Acute bronchitis Followed by a long list of INCLUDES, EXCLUDES1, and EXCLUDES2 notations. Read them all, carefully. None apply to this specific scenario. Now examine the code descriptions for all of the codes in this code category. The only one that fits accurately is J20.8 Acute bronchitis due to other specified organisms The organism is specified – COVID-19 – but there is no specific code description that matches more accurately. So, you now have the two codes to report the reasons for Lillie’s hospital admission: U07.1, J20.8. Good coding!

FOLLOW-UP ENCOUNTERS The longer the world deals with this pandemic, the greater the opportunity you may have to report a reason for a follow-up visit, after the patient has cleared the virus. For these visits, and for those where the patient has now tested negative, report one of two codes, determined by the specifics in the documentation: Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z86.19 Personal history of other infectious and parasitic diseases At an encounter where the patient is coming back in for a COVID-19 antibody test, you need to report Z01.84 Encounter for antibody response examination

Chapter 6 Review Answer Key Let’s Check It! Terminology Part I Answer: 1. J Nosocomial 2. C Bacteria 3. H Infectious 4. D Chronic 5. F Human Immunodeficiency Virus (HIV) 6. E Fungi 7. A Acute 8. G Infection 9. B Asymptomatic 10. I Inflammation

Learning Objective: 06.01 Topic: Infectious and Communicable Diseases Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part II Answer: 1. J Viruses 2. A Parasites 3. B Pathogen 4. E Septicemia 5. F Severe Sepsis 6. H Systemic Inflammatory Response Syndrome (SIRS) 7. G Systemic 8. I Tuberculosis 9. C Sepsis 10. D Septic Shock Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.07 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Septicemia and Other Blood Infections Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts 1. Answer: C increased body temperature

Feedback: The body‘s alert to the existence of infection will be exhibited by specific signs and symptoms such as: increased body temperature; Increased white blood cell count; Increase or decrease in heart rate; Increase or decrease in respiratory rate. Learning Objective: 06.01 Topic: Infectious and Communicable Diseases Blooms: Remember CAAHEP: I.C.1 CAAHEP: IC.8.a CAAHEP: IC.8.b CAAHEP: IX.C.2 ABHES: 2.b ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: B Cellulitis Feedback: Cellulitis is a serious infection of the skin that may be either a staph infection (the staphylococcal bacteria) or a strep infection (the Streptococcal bacteria). Learning Objective: 06.02 Topic: Bacterial Infections Blooms: Remember CAAHEP: I.C.1 CAAHEP: IC.8.a CAAHEP: IC.8.b CAAHEP: IX.C.2 ABHES: 2.b ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: D B02.33 Feedback: The correct code for a diagnosis of Herpes Zoster keratoconjunctivits is B02.33 B02.33: Index>Herpes>zoster>keratitis Learning Objective: 06.03 Topic: Viral Infections Blooms: Understand CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium

Est Time: 0-1 minute 4. Answer: C warts Feedback: Parasites are tiny living things that can invade and feed off other living things—like humans. They are one-celled organisms (protozoa), insects (lice and mites), worms (Helminthiasis), and others that can interfere with a healthy body. Tapeworms, hookworms, and pinworms are internal parasites. Parasites can be transmitted in food (e.g., protozoa like Giardia intestinalis and Cyclospora cayetanensis); spread by mosquitoes and other insects through the bloodstream (as in malaria and leishmaniasis); or ingested in contaminated water (as in amebiasis and schistosomiasis). Learning Objective: 06.04 Topic: Parasitic and Fungal Infections Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: B bacterial infection Feedback: Aspiration pneumonia is a bacterial infection that develops after the patient has inhaled food, a liquid, or vomit. The particles deteriorate and bacteria grows, causing the infection and inflammation. Learning Objective: 06.05 Topic: Infections Caused by Several Pathogens Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 6. Answer: D O98.712 Feedback: When a woman with HIV-positive status is pregnant, giving childbirth, or in the postpartum period, the systemic disease must be a consideration in determining her care. Therefore, whether or not she has symptoms or manifestations of the HIV condition, the first-listed code must be: O978.712: Index>Pregnancy>HIV O98.712: Human immunodeficiency virus [HIV] disease complicating pregnancy, second trimester. Learning Objective: 06.06

Topic: Immunodeficiency Conditions Blooms: Understand CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 7. Answer: C Z20.6 Feedback: The correct code for exposure to HIV is Z20.6 Z20.6: Index>exposure (to)> human immunodeficiency virus [HIV] Learning Objective: 06.06 Topic: Immunodeficiency Conditions Blooms: Understand CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 8. Answer: C the code for the underlying condition, the code for SIRS, the code for the acute organ dysfunction Feedback: Systemic inflammatory response syndrome (SIRS) can develop in patients who have not developed an infection. Instead the reaction may occur due to the presence of a burn or other trauma, a malignant neoplasm, or the presence of pancreatitis. In such cases, coding the condition will change slightly. You will code the following sequence: First: the code for the underlying condition (e.g., T22.311-Third-degree burn of forearm) Followed by: a code for SIRS from the subcategory R65.1-Systemic inflammatory response syndrome. Followed by: a code for the acute organ dysfunction, when applicable. Learning Objective: 06.07 Topic: Septicemia and Other Blood Infections Blooms: Understand CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 9. Answer: A the first-listed diagnosis code.

Feedback: The code for septic shock may not be the principal or first-listed diagnosis. Septic shock cannot be present without the existence of severe sepsis—and it all must be documented. When coding septic shock, report the codes in the following order: 1. The code for the systemic infection (e.g., A40.-.) 2. The code for the severe sepsis with septic shock (e.g., R65.21.) 3. The code for the organ dysfunction. Learning Objective: 06.07 Topic: Septicemia and Other Blood Infections Blooms: Understand CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: C both direct and indirect contact Feedback: Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterial (staph) infection that is essentially unaffected by certain antibiotics. MRSA is spread from one person to another by direct contact with the infection, such as touching a skin bump or infection that is draining pus. MRSA can be spread directly, for example, by touching an infected person‘s rash, or it can be spread indirectly, such as by touching a used bandage contaminated with MRSA or by sharing a towel or razor that has come in contact with infected skin. One of the most frequent anatomical sites of MRSA colonization is the nose; bacteria can be found in nasal secretions.

To properly report these diagnoses, code the current infection due to MRSA and the MRSA infection separately with code: A49.02 Methicillin resistant Staphylococcus aureus infection, unspecific site B95.62 Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere Learning Objective: 06.08 Topic: Antimicrobial Resistance Blooms: Remember CAAHEP: I.C.1 CAAHEP: IC.8.a CAAHEP: IC.8.b CAAHEP: IX.C.2 ABHES: 2.b ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Guidelines

1. Answer: confirmed; Section II, H Feedback: I.C.1.a.1 Code only confirmed cases of HIV infection/illness. This is an exception to the hospital inpatient guideline Section II, H. Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 2. Answer: unrelated, principal Feedback: I.C.1.a.2.b If a patient with HIV disease is admitted for an unrelated condition, the code for the unrelated condition should be the principal diagnosis. Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens

Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 3. Answer: inconclusive, diagnosis, R75 Feedback: I.C.1.a.2.e Patients with inconclusive HIV serology, but no definitive diagnosis or manifestations of the illness, may be assigned code R75. Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 4. Answer: informed, Z71.7 Feedback: I.C.1.a.2.h When a patient returns to be informed of his/her HIV test results and the test is negative, use code Z71.7. Learning Objective: 06.01 Learning Objective: 06.02

Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 5. Answer: urosepsis, synonymous, queried Feedback: I.C.1.d.1.a.ii The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. Should a provider use this term, he/she must be queried for clarification. Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 6. Answer: 2, underlying, R65.2 Feedback: I.C.1.d.1.b The coding of sever sepsis requires a minimum of 2 codes: first code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 7. Answer: septic, severe, organ Feedback: I.C.1.d.2.a Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction. Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07

Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 8. Answer: postprocedural, documentation, infection Feedback: I.C.1.d.5.a As with all postprocedural complications, code assignment is based on the provider‘s documentation of the relationship between the infection and the procedure. Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes

9. Answer: sepsis; I.C.16.f Feedback: I.C.1.d.8 Newborn sepsis see Section I.C.16.f. Bacterial sepsis of Newborn Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 10. Answer: B95.62 Feedback: I.C.1.e.1.b When there is documentation of a current infection due to MRSA, and that infection does not have a combination code that includes the causal organism, assign the appropriate code to identify the condition along with code B95.62, Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere for the MRSA infection. Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections

Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes Let‘s check It! Rules and Regulations 1. Answer: Answers may vary. A bacterial infection is an infection caused by bacteria which is a single-celled microorganism named for their shape. Some examples would be diphtheria, tetanus and tuberculosis. A viral infection is an infection caused by a virus which is a microscopic particle that initiates disease, mimicking the characteristics of a particular cell and can reproduce only within the body of the cell which it has invaded. A virus is difficult to isolate and can be dormant for long periods of time. Some examples would be varicella, hepatitis and the common cold. Feedback: A bacterial infection is an infection caused by bacteria which is a single-celled microorganism named for their shape. Some examples would be diphtheria, tetanus and tuberculosis. A viral infection is an infection caused by a virus which is a microscopic particle that initiates disease, mimicking the characteristics of a particular cell and can reproduce only within the body of the cell which it has invaded. A virus is difficult to isolate and can be dormant for long periods of time. Some examples would be varicella, hepatitis and the common cold. Learning Objective: 06.02 Learning Objective: 06.03 Topic: Bacterial Infections Topic: Viral Infections Blooms: Understand CAAHEP: I.C.1 CAAHEP: IC.8.a CAAHEP: IC.8.b CAAHEP: IX.C.2 ABHES: 2.b ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes

2. Answer: Answers may vary. Parasites are tiny living things that can invade and feed off other living things—like humans. They are one-celled organisms, insects, and worms among others that can interfere with a healthy body. Tapeworms, hookworms, and pinworms are internal parasites. Parasites can be transmitted in food (e.g., protozoa like Giardia intestinalis and Cyclospora cayetanensis); spread by mosquitoes and other insects through the bloodstream (as in malaria and leishmaniasis); or ingested in contaminated water (as in amebiasis and schistosomiasis).

Fungi is a group of organisms, including mold, yeast, and mildew, that cause infection; fungus (singular). Except in patients with compromised immune systems, fungal infections are not life-threatening. Examples of fungal infections are aspergillus, Candida albicans, and Onychomycosis. Feedback: Parasites are tiny living things that can invade and feed off other living things— like humans. They are one-celled organisms, insects, and worms among others that can interfere with a healthy body. Tapeworms, hookworms, and pinworms are internal parasites. Parasites can be transmitted in food (e.g., protozoa like Giardia intestinalis and Cyclospora cayetanensis); spread by mosquitoes and other insects through the bloodstream (as in malaria and leishmaniasis); or ingested in contaminated water (as in amebiasis and schistosomiasis).

Fungi is a group of organisms, including mold, yeast, and mildew, that cause infection; fungus (singular). Except in patients with compromised immune systems, fungal infections are not life-threatening. Examples of fungal infections are aspergillus, Candida albicans, and Onychomycosis. Learning Objective: 06.04 Topic: Parasitic and Fungal Infections Blooms: Understand CAAHEP: I.C.1 CAAHEP: IC.8.a CAAHEP: IC.8.b CAAHEP: IX.C.2 ABHES: 2.b ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes

3. Answer: Nosocomial infections or Healthcare-acquired infections (HAI) are those conditions that are contracted solely due to interactions with a healthcare facility during which exposure to various types of pathogens occurs. Nosocomial infections or HAIs are infections that occur in hospitals, outpatient clinics, nursing homes, and other healthcare provider locations. Feedback: Nosocomial infections or Healthcare-acquired infections (HAI) are those conditions that are contracted solely due to interactions with a healthcare facility during which exposure to various types of pathogens occurs.

Nosocomial infections or HAIs are infections that occur in hospitals, outpatient clinics, nursing homes, and other healthcare provider locations. Learning Objective: 06.01 Topic: Infectious and Communicable Diseases Blooms: Understand CAAHEP: I.C.1 CAAHEP: IC.8.a CAAHEP: IC.8.b CAAHEP: IX.C.2 ABHES: 2.b ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: Septicemia is identified as the presence of a microorganism or toxin in the bloodstream. The organism might be a virus, a fungus, bacteria, or another pathologic substance. Septicemia is very serious and always significant. Systemic inflammatory response syndrome (SIRS) is a definite physical reaction, such as fever, chills, etc., to an unspecified pathogen. A diagnosis of SIRS is used when the basic cause, or pathogen, is unknown. Feedback: Septicemia is identified as the presence of a microorganism or toxin in the bloodstream. The organism might be a virus, a fungus, bacteria, or another pathologic substance. Septicemia is very serious and always significant. Systemic inflammatory response syndrome (SIRS) is a definite physical reaction, such as fever, chills, etc., to an unspecified pathogen. A diagnosis of SIRS is used when the basic cause, or pathogen, is unknown. Learning Objective: 06.07 Topic: Septicemia and Other Blood Infections Blooms: Understand CAAHEP: I.C.1 CAAHEP: IC.8.a CAAHEP: IC.8.b CAAHEP: IX.C.2 ABHES: 2.b ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterial (staph) infection that is essentially unaffected by certain antibiotics. MRSA is spread from one person to another by direct contact with the infection.

Feedback: Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterial (staph) infection that is essentially unaffected by certain antibiotics. MRSA is spread from one person to another by direct contact with the infection. Learning Objective: 06.08 Topic: Antimicrobial Resistance Blooms: Understand CAAHEP: I.C.1 CAAHEP: IC.8.a CAAHEP: IC.8.b CAAHEP: IX.C.2 ABHES: 2.b ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Basics Answer: aspergillosis, B44.81 Feedback: Allergic bronchopulmonary aspergillosis: aspergillosis, B44.81 B44.81: Index>aspergillosis>bronchopulmonary, allergic Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: Hepatitis C, K73.2

Feedback: Chronic active Hepatitis C: Hepatitis C, K73.2 K73.2: Index>hepatitis>C>chronic>active Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: Sepsis, A40.1 Feedback: Sepsis, streptococcal, group B: Sepsis, A40.1 A40.1: Index>sepsis>streptococcal>group B Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4. Answer: cryptococcosis, B45.0 Feedback: Pulmonary cryptococcosis: cryptococcosis, B45.0 B45.0: Index>cryptococcosis>pulmonary Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 5. Answer: meningitis, B02.1 Feedback: Herpes zoster meningitis: meningitis, B02.1 B02.1: Index>meningitis>in>herpes virus>zoster Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08

Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 6. Answer: otitis, H66.91 Feedback: Chronic otitis media, right ear: otitis, H66.91 H66.90: Index>otitis>media>chronic>right Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 7. Answer: fever, A95.0 Feedback: Jungle Yellow fever: fever, A95.0

A95.0: Index>fever>yellow>jungle Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 8. Answer: sarcoma, C46.3 Feedback: Kaposi‘s sarcoma of the lymph nodes: sarcoma, C46.3 C46.3: Index>sarcoma>Kaposi‘s>lymph nodes Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 9. Answer: cellulitis, L03.113 Feedback: Cellulitis of upper right limb: cellulitis, L03.113 L03.113: Index>cellulitis>axilla>right Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 10. Answer: blastomycosis, B40.7 Feedback: Generalized blastomycosis: blastomycosis, B40.7 B40.7: Index>blastomycosis>generalized Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases

Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 11. Answer: encephalomyelitis, G04.81 Feedback: Acute disseminated, noninfectious, encephalomyelitis: encephalomyelitis, G04.81 G04.81: Index> encephalomyelitis>acute disseminated>noninfectious Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 12. Answer: Diphtheria, A36.2 Feedback: Laryngeal Diphtheria: Diphtheria, A36.2

A36.2: Index>diphtheria>laryngeal Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 13. Answer: tuberculosis, A18.39 Feedback: 13. Retroperitoneal tuberculosis: tuberculosis, A18.39 A18.39: Index>tuberculosis>retroperitoneal Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 14. Answer: shigellosis, A03.2 Feedback: Shigellosis, group C: shigellosis, A03.2 A03.2: Index>shigellosis>group C Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 15. Answer: ringworm, B35.0 Feedback: Ringworm honeycomb: ringworm, B35.0 B35.0: Index>ringworm>honeycomb Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases

Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes You Code It! Practice 1. Answer: A92.30 Feedback: A92.30: Index>Fever>West>Nile>unspecified Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 2.

Answer: J09.X2 Feedback: J09.X2: Index>influenza>swine Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 3. Answer: B87.3 Feedback: B87.3: Index>myiasis>nasopharyngeal Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 4. Answer: A98.4 Feedback: A98.4: Index>Ebola virus disease Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 5. Answer: B15.9 Feedback: B15.9: Index>hepatitis>type>A Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections

Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 6. Answer: A37.01, H11.32 Feedback: A37.01: Index>whooping cough>due to >Bordetella> pertussis>with>pneumonia H11.32: Index>hemorrhage>conjunctiva>left Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 7. Answer: O98.713, B20, B01.2, Z3A.28 Feedback: O98.713: Index>pregnancy>complicated by>HIV>third trimester

B20: Index>HIV B01.2: Index>Varicella>with>pneumonia Z3A.28: Index>pregnancy>weeks of gestation>28 weeks Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 8. Answer: A38.9 Feedback: A38.9: Index>Fever>scarlet>uncomplicated Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 9. Answer: A15.4 Feedback: A15.4: Index>Tuberculosis>tracheobronchial>lymph glands or nodes Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 10. Answer: A40.1, R65.20, K72.00 Feedback: A40.1: Index>Sepsis>streptococcal>group B R65.20: Index>Sepsis>sever>without shock K72.00: Index>Failure>hepatic>acute Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06

Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 11. Answer: A59.02 Feedback: A59.02: Index>Prostatitis>trichomonal Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 12. Answer: B06.9

Feedback: B06.9: Index>Measles Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 13. Answer: B27.00 Feedback: B27.00: Index>Mononucleosis, infectious>Epstein-Barr Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 14. Answer: B33.23 Feedback: B33.23: Index>Coxsackie>pericarditis Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 15. Answer: A06.4 Feedback: A06.4: Index>abscess>liver>amebic Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections

Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes You Code It! Application Application 1: Galeana, Robert Answer: A87.8, A95.1, H66.002 Feedback: A87.8: index>meningitis>arbovirus A95.1: index>Fever>yellow>urban H66.002: index>Otitis>media>suppurative>acute

Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Application 2: Murphy, Adreienne

Answer: B20, B00.52 Feedback: B20: Index>HIV B00.52: Index>Herpes>keratoconjunctivitis Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Application 3: Lupo, Theresa Answer: S81.022A, L03.116, B95.2, W07.XXXA, Y92.017 Feedback: S81.022A: Index>Laceration>knee>with>foreign body>left>initial encounter L03.116: Index>Cellulitis>lower limb>left B95.2: Index>Streptococcal>group>D, as cause of disease classified elsewhere Providing External Cause codes for instructors: W07.XXXA: Index>External Causes index>fall, falling>from, off, out of>chair>initial encounter Y92.017: Index>External Causes index>place of occurrence>residence>house, single family>yard Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06

Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Application 4: Plattenbaum, Benjamin Answer: J01.10, B95.62, Z16.11 Feedback: J01.10 Index>sinusitis>frontal>acute>unspecified B95.62 Index>Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere Z16.11 Index>Resistance>organism>to drug> penicillin Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 1-3 minutes Application 5: Samules, Bernard Answer: J11.08, J15.5, A41.51, R65.21, N17.9 Feedback: J11.08: Index>Influenza>with>pneumonia>unspecified J15.5: Index>Pneumonia>Escherichia coli A41.51: Index>Sepsis>Escherichia coli R65.21: Index>Sepsis>sever>with septic shock N17.9: Index>Failure>renal>acute>unspecified Learning Objective: 06.01 Learning Objective: 06.02 Learning Objective: 06.03 Learning Objective: 06.04 Learning Objective: 06.05 Learning Objective: 06.06 Learning Objective: 06.07 Learning Objective: 06.08 Topic: Infectious and Communicable Diseases Topic: Bacterial Infections Topic: Viral Infections Topic: Parasitic and Fungal Infections Topic: Infections Caused by Several Pathogens Topic: Immunodeficiency Conditions Topic: Septicemia and Other Blood Infections Topic: Antimicrobial Resistance Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Chapter 7 Review Coding Neoplasms 2024 Compliant Learning Outcomes LO 7.1 Identify the medical necessity for screenings and diagnostic testing for malignancies. LO 7.2 Discern the various types of neoplasms. LO 7.3 Interpret the Table of Neoplasms accurately.

LO 7.4 Employ the directions provided in the Chapter Notes at the head of the Neoplasms section of the Tabular List. LO 7.5 Apply the guidelines for sequencing admissions due to complications of neoplasms and/or their treatments.

Chapter Outline Learning Outcomes Key Terms Screening and Diagnosis Screenings Confirming a Diagnosis Test Results Abstracting the Details About Neoplasms Terms Used to Identify Neoplasms Malignant Primary Malignant Secondary Ca In Situ Benign Uncertain Unspecified Behavior Reporting the Neoplasm Diagnosis A Pregnant Patient with a Malignancy Malignancies in Remission or Relapse Neoplasm Chapter Notes Functional Activity Morphology (Histology) Primary Malignant Neoplasms Overlapping Site Boundaries Malignant Neoplasms of Ectopic Tissue Admissions Related to Neoplastic Treatments Admission for Treatment of Malignancy Excised Malignancies/Personal History Complications and Complications of Treatment Treatment of Secondary Site Only Prophylactic Organ Removal Chapter Summary Chapter 7 Review

Let‘s Check It! Terminology Let‘s Check It! Concepts Let‘s Check It! Guidelines Let‘s Check It! Rules and Regulations You Code It! Practice You Code It! Application

Chapter Overview When normal cells mutate, they may create a neoplasm, also known as a tumor. Even though the health care industry is making tremendous accomplishments in the battle against cancer (malignant neoplasms), there may still be many different situations when your students may have to code a patient with this diagnosis. Discussion Activities 1. Screenings and Diagnostic Testing [Learning Outcome: 7.1]

The advancement of preventive and early detection testing has brought about many more patients surviving a malignancy and maintaining quality of life. a. How will a coder recognize if a test is a screening or diagnostic test? b. Identify an example of a screening and report the code the diagnosis code used to justify this procedure.

a. Students should discuss the presence of signs and symptoms that would lead to a diagnostic test whereas a screening is done based on a specific date on the calendar. b. Examples of screenings include mammograms, prostate screenings, Pap smears, chest x-ray, and more. 2. Benign or Malignant; Primary or Secondary [Learning Outcome: 7.2] a. How does a coder know if the patient‘s neoplasm is benign or malignant? Include examples of names that may report one or the other. b. How can a coder distinguish if a confirmed malignancy is primary or secondary? What is the difference?

a. Coders should look at the diagnostic statement as well as the pathology report. Specific terms identifying neoplasms: adenoma (benign); blastoma (malignant); sarcoma (malignant).

b. Documentation that includes terms or phrases such as: metastatic, metastasis, spread from, and spread to would refer to secondary malignancy. A primary malignancy is the first identified. 3. Cancer Registries: Career Opportunities a. Why have cancer registries been created? b. Why is it important to have these registries track the diagnosis, treatment, and prognosis of patients diagnosed with different types of neoplasms? Discuss the role that cancer registries play in the healthcare industry. Have students research cancer registries in their area. Review what additional education a professional coding specialist needs to become a cancer registrar.

Additional Resources Tumor (MedlinePlus): http://www.nlm.nih.gov/medlineplus/ency/article/001310.htm Cancer (MedlinePlus): http://www.nlm.nih.gov/medlineplus/cancer.html Benign Tumors (MedlinePlus): http://www.nlm.nih.gov/medlineplus/benigntumors.html Brain tumor – primary – adults (MedlinePlus): http://www.nlm.nih.gov/medlineplus/ency/article/007222.htm Metastasis (MedlinePlus): http://www.nlm.nih.gov/medlineplus/ency/article/002260.htm Grey’s Anatomy Online: http://www.bartleby.com/107/ Stedman’s Medical Dictionary: http://www.stedmans.com/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html American Medical Association: http://www.ama-assn.org American Hospital Association: http://www.aha.org American Health Information Management Association: http://www.ahima.org AAPC: http://www.aapc.com

ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 7 Review Answer Key Let’s Check It! Terminology Answer: 1. E Malignant 2. D Functional Activity 3. A Benign 4. B Carcinoma 5. I Neoplasm 6. G Metastasize 7. C Ectopic

8. K Topography 9. J Overlapping Boundaries 10. F Mass 11. H Morphology Learning Objective: 07.02 Learning Objective: 07.04 Topic: Abstracting the Details About Neoplasms Topic: Neoplasm Chapter Notes Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minute Let‘s Check It! Concepts 1. Answer: A tumor Feedback: A neoplasm is abnormal tissue growth; tumor. Learning Objective: 07.02 Topic: Abstracting the Details About Neoplasms Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: D chemotherapy Feedback: Neoplasms include adenoma, melanoma, leukemia and papilloma. Chemotherapy is a type of treatment for malignant neoplasms. Learning Objective: 07.02 Topic: Abstracting the Details About Neoplasms Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: B Ca in situ

Feedback: The term Ca in situ indicates that the tumor has undergone malignant changes but is still limited to the site where it originated (i.e., it has not spread).

Learning Objective: 07.02 Topic: Abstracting the Details About Neoplasms Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

4. Answer: C to describe the topography and histology of the neoplasm Feedback: Morphology is the study of the configuration or structure of living organisms. Morphology identifies the behavior and histology of the neoplasm. M codes are used for providing specific data about the site (topography) and the histology (morphology) of the affected tissue to tumor and cancer registries. Pathologists may also use the codes to provide more detail about a particular tissue sample. Normally, M codes are not used for reimbursement and are not placed on insurance claim forms. Cancer registries use them in their cataloging of data. Learning Objective: 07.04 Topic: Neoplasm Chapter Notes Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 5. Answer: A personal history of malignancy code Feedback: Thanks to modern medical science and technology, health care professionals are more successful than ever at getting rid of certain neoplasms (tumors), often by excising them, or cutting them out. When that happens, the patient no longer has the site of the malignancy and, therefore, can no longer have that condition. At that time, the code will change from a malignancy code (C00–C96) to a personal history of a malignancy code (category Z85). Learning Objective: 07.05 Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute

6. Answer: C the chemotherapy Feedback: When the encounter is only for therapeutic treatment of a malignancy, such as the administration of chemotherapy, immunotherapy, or radiation therapy, then the principal (first listed) code will report this fact, followed by a code or codes to report details about the malignancy being treated. Learning Objective: 07.05 Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 7. Answer: B first Feedback: If the patient is admitted for treatment of a complication as the result of the neoplastic treatment, (chemotherapy or immunotherapy) you will report a code for the complication (anemia or dehydration) first, followed by code T45.1x5- Adverse effect of antineoplastic and immunosuppressive drugs [seventh character is required to identify the encounter].

Learning Objective: 07.05 Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute

8. Answer: C C90.31 Feedback: C90.31: index>plasmacytoma>solitary>in remission Learning Objective: 07.03 Topic: Reporting the Neoplastic Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9.

Answer: B CA-125 Feedback: The common diagnostic tests for suspected malignancy of the lung are: Malignant Neoplasm of the Lung • Alpha-1 antitrypsin • Bone scan • Bronchoscopy • Chest x-ray • Lung biopsy Learning Objective: 07.01 Topic: Screening and Diagnosis Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: D all of these Feedback: To determine the code to report a neoplasm, you need to know: 1. Where in the body (specifically, which anatomical site) is the neoplasm located? 2. Is the neoplasm benign, malignant, in situ, or uncertain? Uncertain is a pathologic determination and is not the same as unspecified. 3. If the neoplasm is malignant, is this the first diagnosis of malignancy for this patient? If so, this is the primary site. If not, this is a secondary malignancy because it metastasized from the primary. Learning Objective: 07.02 Topic: Abstracting the Details About Neoplasms Blooms: Understand CAAHEP: IX.C.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute Let’s Check It! Guidelines 1. Answer: properly, benign Feedback: I.C.2: To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. Learning Objective: 07.01

Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 2. Answer: principal Feedback: I.C.2.a: If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 3. Answer: primary, metastasis Feedback: I.C.2.b: When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present. Learning Objective: 07.01 Learning Objective: 07.02

Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 4. Answer: anemia, first-listed Feedback: I.C.2.c.1: When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or firstlisted diagnosis followed by the appropriate code for the anemia. Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 5. Answer: dehydration, malignancy Feedback: I.C.2.c.3: When the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.

Learning Objective: 07.01 Learning Objective: 07.02

Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 6. Answer: excised, Z85 Feedback: I.C.2.d: When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 7. Answer: Z51.0, Z51.11, Z51.12 Feedback: I.C.2.e.2: If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy assign code Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11,

Encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis. Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 8. Answer: extent Feedback: I.C.2.f: When the reason for admission/encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal or first-listed diagnosis, even though chemotherapy or radiotherapy is administered.

Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 9. Answer: principal/first-listed

Feedback: I.C.2.l.1: If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the principal/first-listed diagnosis. Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 10. Answer: pathological, M84.5, first Feedback: I.C.2.l.6: When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by the code for the neoplasm. Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes Let’s Check It! Rules and Regulations

1. Answer: Benign is not infectious or spreading; nonmalignant characteristic of a neoplasm. Malignant has invasive and destructive characteristic of a neoplasm; possibly causing damage or death. Feedback: Benign is not infectious or spreading; nonmalignant characteristic of a neoplasm. Malignant has invasive and destructive characteristic of a neoplasm; possibly causing damage or death. Learning Objective: 07.02 Topic: Abstracting the Details About Neoplasms Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: Primary indicates the anatomical site (the place in the body) where the malignant neoplasm was first seen and identified. If the physician‘s notes do not specify primary or secondary, then the site mentioned is primary.

Secondary identifies the anatomical site to which the malignancy metastasized (spread). The notes will state that a site is ―secondary to‖ (primary site), ―metastasized from‖ (primary site), or (primary site) ―metastasized to‖ (secondary site). Ca in situ indicates that the tumor has undergone malignant changes but is still limited to the site where it originated (i.e., it has not spread). Ca is short for carcinoma, and you can remember situ as in the word situated. So, it is a cancerous tumor that is staying in place. The classification uncertain indicates that the pathologist is not able to specifically determine whether a tumor is benign or malignant because indicators of both are present. Choose codes which describe ―Unspecified Behavior‖ when the physician‘s notes do not include any specific information regarding the nature of the tumor. Before choosing one of these codes, please query the physician and make certain that a laboratory report is not available or on its way with the information you need. Feedback: Primary indicates the anatomical site (the place in the body) where the malignant neoplasm was first seen and identified. If the physician‘s notes do not specify primary or secondary, then the site mentioned is primary.

Secondary identifies the anatomical site to which the malignancy metastasized (spread). The notes will state that a site is ―secondary to‖ (primary site),

―metastasized from‖ (primary site), or (primary site) ―metastasized to‖ (secondary site). Ca in situ indicates that the tumor has undergone malignant changes but is still limited to the site where it originated (i.e., it has not spread). Ca is short for carcinoma, and you can remember situ as in the word situated. So, it is a cancerous tumor that is staying in place. The classification uncertain indicates that the pathologist is not able to specifically determine whether a tumor is benign or malignant because indicators of both are present. Choose codes which describe ―Unspecified Behavior‖ when the physician‘s notes do not include any specific information regarding the nature of the tumor. Before choosing one of these codes, please query the physician and make certain that a laboratory report is not available or on its way with the information you need. Learning Objective: 07.02 Topic: Abstracting the Details About Neoplasms Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: Overlapping boundaries are multiple sites of carcinoma without identifiable borders, also known as contiguous. Neoplasms with overlapping or contiguous boundaries may blur the anatomical descriptors.

Feedback: Overlapping boundaries are multiple sites of carcinoma without identifiable borders, also known as contiguous. Neoplasms with overlapping or contiguous boundaries may blur the anatomical descriptors. Learning Objective: 07.04 Topic: Neoplasm Chapter Notes Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: In addition to the code for a neoplasm, you may be required to include an M code. The M stands for morphology, and the M code identifies the behavior and histology of the neoplasm.

―Morphology of Neoplasms‖ is available as a separate book, the International Classification of Diseases for Oncology (ICD-O). Morphology codes are not structured like the other diagnosis codes. The codes always begin with the letter ―M,‖ which is followed by four characters, a slash (/), and a single character. The neoplasm‘s histology is described by the first four characters of the M code. M codes are used for providing specific data about the site (topography) and the histology (morphology) of the affected tissue to tumor and cancer registries. Pathologists may also use the codes to provide more detail about a particular tissue sample. Normally, M codes are not used for reimbursement and are not placed on insurance claim forms. Feedback: In addition to the code for a neoplasm, you may be required to include an M code. The M stands for morphology, and the M code identifies the behavior and histology of the neoplasm. ―Morphology of Neoplasms‖ is available as a separate book, the International Classification of Diseases for Oncology (ICD-O). Morphology codes are not structured like the other diagnosis codes. The codes always begin with the letter ―M,‖ which is followed by four characters, a slash (/), and a single character. The neoplasm‘s histology is described by the first four characters of the M code. M codes are used for providing specific data about the site (topography) and the histology (morphology) of the affected tissue to tumor and cancer registries. Pathologists may also use the codes to provide more detail about a particular tissue sample. Normally, M codes are not used for reimbursement and are not placed on insurance claim forms. Learning Objective: 07.04 Topic: Neoplasm Chapter Notes Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: Advances in science have given us genetic predisposition testing and other identification exams. The information these tests provide, along with personal and family histories, enables patients and health care professionals to predict an individual‘s risk for cancer and other diseases more accurately. Studies show, for example, that a woman who has inherited a mutation in the BRCA1 or BRCA2 gene faces a dramatically higher risk for developing breast cancer by age 65. A strong family history of colon cancer may lead an individual to be tested for a variant in the APC gene. There are many genes that can now be tested for various hereditary or familial conditions.

Prophylactic, or preventive, surgery can reduce risk of cancer in these situations by as much as 90%. In the case of breast cancer, preventative action would mean having a double mastectomy (the surgical removal of both

breasts) while a patient is still healthy and without any signs or symptoms of carcinoma. As a coder, the question becomes: How do you code a diagnosis for a surgical procedure on a healthy anatomical site? You will use: Z40.0 Encounter for prophylactic surgery for risk factors related to malignant neoplasms (Admission for prophylactic organ removal) Use additional code to identify risk factor For those patients who have had genetic testing with a confirmed abnormal gene, you will also use a second code from category Z15 Genetic susceptibility to disease. If the reason for the preventive surgery is due to a family history of cancer, you will add another code from the Z80 Family history of primary malignant neoplasm category. Feedback: Advances in science have given us genetic predisposition testing and other identification exams. The information these tests provide, along with personal and family histories, enables patients and health care professionals to predict an individual‘s risk for cancer and other diseases more accurately. Studies show, for example, that a woman who has inherited a mutation in the BRCA1 or BRCA2 gene faces a dramatically higher risk for developing breast cancer by age 65. A strong family history of colon cancer may lead an individual to be tested for a variant in the APC gene. There are many genes that can now be tested for various hereditary or familial conditions.

Prophylactic, or preventive, surgery can reduce risk of cancer in these situations by as much as 90%. In the case of breast cancer, preventative action would mean having a double mastectomy (the surgical removal of both breasts) while a patient is still healthy and without any signs or symptoms of carcinoma. As a coder, the question becomes: How do you code a diagnosis for a surgical procedure on a healthy anatomical site? You will use: Z40.0 Encounter for prophylactic surgery for risk factors related to malignant neoplasms (Admission for prophylactic organ removal) Use additional code to identify risk factor For those patients who have had genetic testing with a confirmed abnormal gene, you will also use a second code from category Z15 Genetic susceptibility to disease. If the reason for the preventive surgery is due to a family history of cancer, you will add another code from the Z80 Family history of primary malignant neoplasm category. Learning Objective: 07.05 Topic: Admissions Related to Neoplastic Treatments Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1

Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Basics 1. Answer: leukemia, C94.22 Feedback: Acute megakaryocytic leukemia in relapse: leukemia, C94.22 C94.22: Index>leukemia>acute megakaryocytic>in relapse Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: neoplasm, D28.2 Feedback: Benign neoplasm of uterine ligament, broad: neoplasm, D28.2 D28.2: Index>neoplasm table>uterus>ligament>broad>benign Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: adenocarcinoma, D05.12 Feedback: Papillary adenocarcinoma, intraductal, left breast: adenocarcinoma, D05.12 D05.12: Index>adenocarcinoma>papillary>intraductal>breast>left Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4. Answer: tumor, C7A.029 Feedback: Malignant carcinoid tumor of the colon: tumor, C7A.029 C7A.029: Index>tumor>carcinoid>malignant>colon Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes

5. Answer: hemangioma, D18.03 Feedback: Hemangioma of intra-abdominal structures: hemangioma, D18.03 D18.03: Index>hemangioma>intra-abdominal Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 6. Answer: adenoma, D13.4 Feedback: Adenoma of the liver cell: adenoma, D13.4 D13.4: Index>adenoma>liver cell Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 7. Answer: lymphoma, C82.25

Feedback: Follicular grade III lymphoma lymph nodes of inguinal region and lower limbs: lymphoma, C82.25 C82.25: Index>lymphoma>follicular>grade>III>of inguinal region and lower limbs Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 8. Answer: melanoma, C43.71 Feedback: Acral lentiginous, right heel melanoma: melanoma, C43.71 C43.71: Index>melanoma>skin>heel>right Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 9. Answer: lipoma, D17.71 Feedback: Lipoma of the kidney: lipoma, D17.71

D17.71: Index>lipoma>kidney Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 10. Answer: neoplasm, C50.421 Feedback: Primary malignant neoplasm of right male breast, upper-outer quadrant: neoplasm, C50.421 C50.421: Index>neoplasm table>breast>upper outer quadrant>malignant primary>male>right Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 11. Answer: tumor, C41.0 Feedback: Malignant odontogenic tumor, upper jaw bone: tumor, C41.0 C41.0: Index>tumor>odontogenic>malignant>upper jaw bone

Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 12. Answer: neoplasm, C79.89 Feedback: Secondary malignant neoplasm of vallecula: neoplasm, C79.89 C79.89: Index>neoplasm table>vallecula>malignant secondary Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 13. Answer: neoplasm, D09.22 Feedback: Carcinoma in situ neoplasm of left eyeball: neoplasm, D09.22 C09.22: Index>neoplasm table>eyeball>Ca in situ>left Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03

Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 14. Answer: neoplasm, D33.1 Feedback: Benign neoplasm of cerebrum peduncle: neoplasm, D33.1 D33.1: Index>neoplasm table>cerebrum>peduncle>benign Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 15. Answer: myelofibrosis, D47.4 Feedback: Myelofibrosis with myeloid metaplasia: myelofibrosis, D47.4 D47.4: Index>myelofibrosis>with myeloid metaplasia Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis

Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes You Code It! Practice 1. Answer: C32.1 Feedback: C32.1: Neoplasm table>larynx>extrinsic>malignant primary Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: D13.7 Feedback: D13.7: Index>Adenoma>islet cell>pancreas Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes

Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: C61, C78.7 Feedback: C61: Neoplasm table>prostate>malignant primary C78.7: Neoplasm table>liver>malignant secondary Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: Z01.01, D31.01 Feedback: Z01.01: Examination>eye>with abnormal findings D31.01: Nevus>conjunctiva>right

Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes

Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: D38.1 Feedback: D38.1: Index>Adenoma>bronchial Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: C88.0 Feedback: C88.0: Index>Waldenström's> Macroglobulinemia Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: C91.00 Feedback: C91.00: Index>Leukemia>acute lymphoblastic Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: C75.1 Feedback: C75.1: Index>neoplasm table>pituitary gland>malignant primary Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9.

Answer: B20, C46.4 Feedback: B20: Index>Human>immunodeficiency virus disease C46.4: Index>Sarcoma>Kaposi‘s>gastrointestinal organ Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: Z40.09, Z80.42 Feedback: Z40.09: Index>prophylactic>organ removal>specified site NEC Z80.42: Index>history>family>malignant neoplasm>prostate Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: v Est Time: 3-5 minutes 11. Answer: D03.22 Feedback: D03.22: Index>melanoma>in situ>ear (external)>left

Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: C38.2 Feedback: C38.2: Neoplasm table>mediastinum>posterior>malignant primary Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: D45 Feedback: D45: Index>Polycythemia>vera Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05

Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: D64.81, T45.1X5A, C23 Feedback: D64.81: Index>anemia>due to>chemotherapy, antineoplastic T45.1X5A: Table of Drugs and Chemicals>antineoplastic NEC>adverse effect>initial encounter C23: Neoplasm Table>gallbladder>malignant, primary Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: C33, Z87.891 Feedback: C33: Neoplasm table>trachea>malignant primary Z87.891: Index>History>personal>tobacco dependence Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04

Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application Application 1: KAHN, SERENA Answer: C43.39, E03.9, Z85.3, Z86.018, Z90.12, Z90.710 Feedback: C43.39: Index>Melanoma>skin>cheek (external) E03.9:

Hypothryoidism

Z85.3: Index>History>personal>malignant>breast Z86.018: Index>History>personal>neoplasm>benign Z90.12: Index>Status>mastectomy>left Z90.710: Index>History>personal>hysterectomy Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: WILSON, DAWSON Answer: E86.0, C50.922, C79.31, C78.7

Feedback: E86.0: Index>Dehydration C50.922: Index>Neoplasm table>breast>malignant primary>male>left C79.31: Index>Neoplasm table>brain>malignant secondary C78.7: Index>Neoplasm table>liver>malignant secondary Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: OAKWOOD, QUENTIN Answer: G89.3, C79.51, C78.7, Z85.46 Feedback: G89.3: Index>Pain>acute>neoplasm related C79.51: Neoplasm table>bone>malignant secondary C78.7: Neoplasm table>liver>malignant secondary Z85.46: Index>History>personal>malignant neoplasm, prostate Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 3-5 minutes Application 4: CHARLES, KAREN Answer: C78.4, C78.5, C78.6, Z85.43, Z90.710 Feedback: C78.4: Neoplasm table>intestine>small>malignant secondary C78.5: Neoplasm table >intestine>large>malignant secondary C78.6: Neoplasm table>omentum>malignant secondary Z85.43: Index>History>personal>malignant neoplasm>ovary Z90.710: Index>History>personal>hysterectomy Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: BENTONN, VERNON Answer: I75.021, C20, C78.7 Feedback: I75.021: Index> Atheroembolism>of>extremities>lower>right C20: Neoplasm table>rectum>malignant primary C78.7 Neoplasm table>liver>malignant secondary Learning Objective: 07.01 Learning Objective: 07.02 Learning Objective: 07.03 Learning Objective: 07.04 Learning Objective: 07.05 Topic: Screening and Diagnosis Topic: Abstracting the Details About Neoplasms Topic: Reporting the Neoplastic Diagnosis Topic: Neoplasm Chapter Notes Topic: Admissions Related to Neoplastic Treatments Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 8 Coding Conditions of the Blood and Immunological Systesm 2024 Compliant Learning Outcomes

LO 8.1 Differentiate between various blood conditions and how this affects the determination of the code. LO 8.2 Determine the codes to report coagulation defects and hemorrhagic conditions accurately. LO 8.3 Identify the different types of blood and the importance of Rh factoring involved in malfunction. LO 8.4 Interpret the details of white blood cell disorders and diseases of the spleen. LO 8.5 Evaluate the factors involved in immunodeficiency disorders. Chapter Outline Learning Outcomes Key Terms Reporting Blood Conditions The Formation of Blood Blood Roles Anemias Sickle Cell Disease and Sickle Cell Trait Coagulation Defects and Other Hemorrhagic Conditions Hemophilia Types of Hemophilia Thrombocytopenia Conditions Related to Blood Types and the Rh Factor Antigens on Red Blood Cells Blood Type Rh Factor Transfusions Disorders of White Blood Cells and Blood-Forming Organs

White Blood Cell Disorders Neutropenia Leukopenia and Leukocytosis Monocytic, Eosinophilic, and Basophilic Conditions Splenic Dysfunction Manifestations of Other Diseases Disorders Involving the Immune System Immunodeficiencies Allergies Sarcoidosis Wiskott-Aldrich Syndrome Chapter Summary Chapter 8 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Rules and Regulations You Code It! Practice You Code It! Application

Chapter Overview Blood is a type of connective tissue consisting of red blood cells (RBCs), white blood cells (WBCs), and platelets (Plats)—all contained within liquid plasma. It is a transportation system for oxygen (nourishment for cells throughout the body) and for carbon dioxide (cell waste products). The average adult has between 5 and 6 liters of blood constantly circulating throughout the body. Diseases and malfunctions of the blood can cause problems for organs and other tissues. In addition, the blood cells are integral parts of the immune function of the body. Dysfunction of the immune system means that the body cannot fight off pathogens nor can it protect it from ensuing diseases.

Discussion Activities 1. Blood Conditions [Learning Outcome: 8.1]

While non-professionals think that ‘anemia’ is a complete diagnosis, hematologists and their coders know there are many different types of anemia, each requiring its own treatment protocol. a. Discuss the various types of anemia and the impact on the body of each? b. Enumerate the signs and symptoms of at least one type of anemia and include the specific code or codes required to report it accurately.

c. Types of anemia include: nutritional, pernicious, hemolytic, aplastic, hemorrhagic, sickle cell. d. Codes will most likely come from the D50-D62 range. 2. Immune System [Learning Outcome: 8.5] Describe the details you need to determine the accurate code for a confirmed allergic response. Include an example with signs and symptoms, and the correct ICD-10-CM code or codes to report this diagnosis.

Additional Resources Blood Disorders (National Heart, Lung, and Blood Institute): http://www.nhlbi.nih.gov/health/resources/blood Blood Disorders (MedlinePlus): http://www.nlm.nih.gov/medlineplus/blooddisorders.html Diseases of the Immune System (NCBI): http://www.ncbi.nlm.nih.gov/books/NBK22243/ What are Autoimmune Disorders? (WebMD): http://www.webmd.com/a-to-zguides/autoimmune-diseases Grey‘s Anatomy Online: http://www.bartleby.com/107/ Stedman‘s Medical Dictionary: http://www.stedmans.com/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html American Medical Association: http://www.ama-assn.org American Hospital Association: http://www.aha.org American Health Information Management Association: http://www.ahima.org AAPC: http://www.aapc.com ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 8 Review Answer Key Let’s Check It! Terminology Answer: 1. E Blood Type 2. P White Blood Cells (WBCs) 3. A Agglutination 4. B Antibody 5. F Coagulation 6. J Hemostasis 7. N Rh factor 8. O Transfusion 9. D Blood 10. K Plasma 11. M Red Blood Cells (RBCs)

12. H Hemoglobin 13. I Hemolysis 14. L Platelets (PLTs) 15. G Hematopoiesis 16. C Antigen Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts 1. Answer: D HCT Feedback: Blood is a type of connective tissue comprised of red blood cells (RBC), white blood cells (WBC), and platelets (Plat) -- all contained within liquid plasma. HCT means hematocrit which is a type of blood test that identifies the percentage of RBC, use to identify anemia. Learning Objective: 08.01 Topic: Reporting Blood Conditions Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: B leukopoiesis Feedback: The red bone marrow produces white blood cells (leukocytes) through a process called leukopoiesis. Learning Objective: 08.01 Topic: Reporting Blood Conditions Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2

ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: D type B- or type OFeedback: An individual with type B- (type B blood, Rh negative) blood can ONLY receive B- blood or type O. Learning Objective: 08.03 Topic: Conditions Related to Blood Types and the Rh Factor Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 4. Answer: D Basophils Feedback: Remember from when you took anatomy class, there are five major types of white blood cells, each of which can malfunction and be unable to perform their jobs keeping the body working properly.

Neutrophils contain enzymes that work to destroy parts of bacterial pathogens that have been consumed by phagocytes. Lymphocytes are critical in the immune response. Monocytes are large blood cells that travel throughout the body and destroy damaged red blood cells. Eosinophils destroys some parasites in addition to controlling inflammation and allergic reactions. Basophils create heparin, a blood thinning agent that prevents inappropriate blood clotting, and create histamines, involved in allergic reactions. Learning Objective: 08.04 Topic: Disorders of White Blood Cells and Blood-Forming Organs Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: B hemolytic anemia

Feedback: Hemolytic anemia (codes D55–D59) results from an insufficient number of healthy red blood cells due to abnormal or premature destruction, thereby retarding the delivery of oxygen to the tissues throughout the body. This premature destruction of the red blood cells may be caused by a genetic defect, an infection, or exposure to certain toxins. Hemolytic anemia can also be caused by a mismatched blood transfusion.

Learning Objective: 08.01 Topic: Reporting Blood Conditions Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

6. Answer: C Thrombocytopenia Feedback: Thrombocytopenia is a low platelet count most often due to increased platelet destruction, decreased platelet production, or malfunctioning platelets. Underlying conditions might include splenomegaly (enlarged spleen); destruction of bone marrow by medication, chemotherapy, or radiation therapy; or aplastic anemia. The condition will be reported most often with a code from ICD-10-CM code category D69 Purpura and other hemorrhagic conditions, although not exclusively. Learning Objective: 08.02 Topic: Coagulation Defects and Other Hemorrhagic Conditions Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 7. Answer: B D57.411 Feedback: The correct code for a patient diagnosed with Sickle-cell thalassemia with acute chest syndrome is D57.411. D57.411: Index>disease>sickle-cell>thalassemia>with>acute chest syndrome Learning Objective: 08.01 Topic: Reporting Blood Conditions Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: A proteins Feedback: Antigens sit on the surface of red blood cells, while antibodies are located within the blood plasma. Antigens are proteins that cause antibodies to form, and each antibody can connect with only one specific type of antigen. Learning Objective: 08.03 Topic: Conditions Related to Blood Types and the Rh Factor Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 9. Answer: C T or B lymphocytes Feedback: Typically, immunodeficiency disorders occur when T or B lymphocytes (special white blood cells) do not work properly. Learning Objective: 08.05 Topic: Disorders Involving the Immune System Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 10. Answer: C Wiskott-Aldrich Syndrome Feedback: Wiskott - Aldrich syndrome is a genetic mutation which causes white blood cells to malfunction, increasing the body‘s susceptibility to inflammatory diseases and other immunodeficiency disorders. Learning Objective: 08.05 Topic: Disorders Involving the Immune System Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Let’s Check It! Rules and Regulations 1. Answer: Blood is actually a type of connective tissue consisting of red blood cells (RBCs), white blood cells (WBCs), and platelets (Plats)—all contained within liquid plasma. It is the transportation system used to deliver oxygen (nourishment) for cells throughout the body and to carry carbon dioxide (cell waste products) so it can be expelled from the body. The average adult has between 5 and 6 liters of blood constantly circulating throughout.

Blood is created in the red bone marrow during a series of steps called hematopoiesis. During gestation, blood cells originate in the yolk sac from the mesenchyme (the section of the embryo in which blood, lymphatic vessels, bones, cartilage, and connective tissues form). As the fetus continues to develop, the liver, spleen, and thymus begin to produce blood cells. Then, at about the 20th week of gestation, the red bone marrow also begins to produce contribute to production. Once the baby is born, blood cell formation becomes the responsibility of the red bone marrow only, specifically in the sternum, ribs, and vertebrae. Red bone marrow produces red blood cells (erythrocytes) through a process called erythropoiesis, and the red bone marrow produces white blood cells (leukocytes) through a process called leukopoiesis. How many blood cells does a healthy body need? Normal counts (per microliter of blood) are:  Red blood cell count: 4 to 6 million cells.  White blood cell count: 4,000 to 11,000 cells.  Platelet count: 150,000 to 400,000 platelets. Feedback: Blood is actually a type of connective tissue consisting of red blood cells (RBCs), white blood cells (WBCs), and platelets (Plats)—all contained within liquid plasma. It is the transportation system used to deliver oxygen (nourishment) for cells throughout the body and to carry carbon dioxide (cell waste products) so it can be expelled from the body. The average adult has between 5 and 6 liters of blood constantly circulating throughout.

Blood is created in the red bone marrow during a series of steps called hematopoiesis. During gestation, blood cells originate in the yolk sac from the mesenchyme (the section of the embryo in which blood, lymphatic vessels, bones, cartilage, and connective tissues form). As the fetus continues to develop, the liver, spleen, and thymus begin to produce blood cells. Then, at about the 20th week of gestation, the red bone marrow also begins to produce contribute to production. Once the baby is born, blood cell formation becomes the responsibility of the red bone marrow only, specifically in the sternum, ribs, and vertebrae. Red bone marrow produces red blood cells (erythrocytes) through a process called erythropoiesis, and the red bone marrow produces white blood cells (leukocytes) through a process called leukopoiesis. How many blood cells does a healthy body need? Normal counts (per microliter of blood) are:

Red blood cell count: 4 to 6 million cells. White blood cell count: 4,000 to 11,000 cells. Platelet count: 150,000 to 400,000 platelets. Learning Objective: 08.01 Topic: Reporting Blood Conditions Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes   

2. Answer: Essentially, there are two types of clotting disorders: hemostatic and thrombotic. A hemostatic disorder is a failure in the system to repair a damaged blood vessel. Because there is no clot to stop it, the vessel continues to bleed. These coagulation deficiencies— where clotting does not occur as it should, may be seen with bleeding into the muscles, joints, and viscera or with the appearance of purpura (dysfunction of blood vessels). Hemophilia is a common hemostatic condition, reported with code D66 Hereditary factor VIII deficiency (Classical hemophilia).

Thrombotic disorders are the opposite: The blood clots without purpose, forming thrombi (blood clots) within the vessels, causing a blockage. Beyond the dangers from the thrombi themselves, should a clot dislodge (embolus) and travel through the blood vessels, it might get caught going through the lungs or heart, causing a blockage that could be deadly. Thrombophilia is an example of a thrombotic condition, reported with, for example, ICD-10-CM code D68.59 Other primary thrombophilia (Hypercoagulable state NOS). Feedback: Essentially, there are two types of clotting disorders: hemostatic and

thrombotic. A hemostatic disorder is a failure in the system to repair a damaged blood vessel. Because there is no clot to stop it, the vessel continues to bleed. These coagulation deficiencies—where clotting does not occur as it should, may be seen with bleeding into the muscles, joints, and viscera or with the appearance of purpura (dysfunction of blood vessels). Hemophilia is a common hemostatic condition, reported with code D66 Hereditary factor VIII deficiency (Classical hemophilia).

Thrombotic disorders are the opposite: The blood clots without purpose, forming thrombi (blood clots) within the vessels, causing a blockage. Beyond the dangers from the thrombi themselves, should a clot dislodge (embolus) and travel through the blood vessels, it might get caught going through the lungs or heart, causing a blockage that could be deadly. Thrombophilia is an example of a thrombotic condition, reported with, for example, ICD-10-CM code D68.59 Other primary thrombophilia (Hypercoagulable state NOS). Learning Objective: 08.02 Topic: Coagulation Defects and Other Hemorrhagic Conditions Blooms: Understand CAAHEP: I.C.1

CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: Due to the existence of antigens located on the surface of the patient‘s red blood cells, any time a patient requires a transfusion of blood, it must be checked for compatibility with regard to type and Rh factor or serious consequences could occur. Because those with type O blood have neither antigen, anyone can accept this blood type. Individuals with type O blood are known as universal donors. Again, Rh factor compatibility must be ensured. A patient with type A+ blood (type A blood, Rh positive) can receive a transfusion of only type A+ blood or type O blood. An individual with type B– blood (type B blood, Rh negative) can receive only type B– blood or type O blood.

Those with type AB blood have both types of antigens, so they can receive type A blood, type B blood, or type O blood. For this reason, they are known as universal recipients. However, attention must still be paid to Rh factor compatibility. The concern about both blood type and Rh factor compatibility arises from the dangers that can happen when the correct antibodies and antigens are not in place. For example, if a Rh-negative patient receives Rh-positive blood, anti-Rh antibodies would be created, causing red blood cell agglutination and hemolysis. Agglutination occurs when antibodies merge with antigens, causing red blood cells to clump together. Hemolysis is the process of cells rupturing—destroying red blood cells and releasing hemoglobin into the bloodstream. Feedback: Due to the existence of antigens located on the surface of the patient‘s red blood cells, any time a patient requires a transfusion of blood, it must be checked for compatibility with regard to type and Rh factor or serious consequences could occur. Because those with type O blood have neither antigen, anyone can accept this blood type. Individuals with type O blood are known as universal donors. Again, Rh factor compatibility must be ensured. A patient with type A+ blood (type A blood, Rh positive) can receive a transfusion of only type A+ blood or type O blood. An individual with type B– blood (type B blood, Rh negative) can receive only type B– blood or type O blood. Those with type AB blood have both types of antigens, so they can receive type A blood, type B blood, or type O blood. For this reason, they are known as universal recipients. However, attention must still be paid to Rh factor compatibility. The concern about both blood type and Rh factor compatibility arises from the dangers that can happen when the correct antibodies and antigens are not in place. For example, if a Rh-negative patient receives Rh-positive blood, anti-Rh antibodies would be created, causing red blood cell agglutination and hemolysis. Agglutination occurs when antibodies merge with antigens, causing red blood cells to clump together. Hemolysis is the

process of cells rupturing—destroying red blood cells and releasing hemoglobin into the bloodstream. Learning Objective: 08.03 Topic: Conditions Related to Blood Types and the Rh Factor Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: Neutropenia is a condition where the patient's bone marrow produces an abnormally low number of white blood cells. This may be an ineffective number of cells being created, or a loss of neutrophils at a rate faster than they can be replaced by new cells. Remember, that white blood cells fight infection. Once created in the bone marrow, these cells are released into the bloodstream, so they can move about the body to wherever they are needed.

A diagnosis of neutropenia may be a congenital condition, an adverse reaction to chemotherapy or other medications, or a malfunction of the hematopoiesis process. Leukopenia is condition where the body is not producing the required number of leukocytes. Of course, while an insufficient quantity of cells is not going to accomplish what is needed by the body, too many can also cause havoc. Leukocytosis is a condition when the body creates too many leukocytes. This may be a correct action because these cells are part of the immune response to certain pathogens. In that case, the elevated while blood cell count would be a sign of an infection, and not reported separately. Without a reason stated, this may be a malfunction, and its own condition. Feedback: Neutropenia is a condition where the patient's bone marrow produces an

abnormally low number of white blood cells. This may be an ineffective number of cells being created, or a loss of neutrophils at a rate faster than they can be replaced by new cells. Remember, that white blood cells fight infection. Once created in the bone marrow, these cells are released into the bloodstream, so they can move about the body to wherever they are needed.

A diagnosis of neutropenia may be a congenital condition, an adverse reaction to chemotherapy or other medications, or a malfunction of the hematopoiesis process. Leukopenia is condition where the body is not producing the required number of leukocytes. Of course, while an insufficient quantity of cells is not going to accomplish what is needed by the body, too many can also cause havoc. Leukocytosis is a condition when the body creates too many leukocytes. This may be a correct action because these cells are part of the immune response to certain pathogens. In that case, the elevated while blood cell count would

be a sign of an infection, and not reported separately. Without a reason stated, this may be a malfunction, and its own condition. Learning Objective: 08.04 Topic: Disorders of White Blood Cells and Blood-Forming Organs Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: The immune system is the armed forces network that develops special forces, known as antibodies, produced by plasma cells in the blood to protect the body from pathogens and other invaders (antigens) that may disrupt proper function. In the previous section, you learned about the role that the different types of white blood cells play in guarding the good health of the body... your immune system.

Researchers continue to study and learn more about the actual mechanisms in place, to employ in the development of more effective and efficient treatments when the body cannot fight alone. The integration of technology and the greater availability of genetic details supports these efforts to eliminate past and current illness and disease, and to fight off or prevent new conditions from evolving. Immunodeficiency disorders are conditions when the patient's immune response is diminished or totally ineffective. Typically, immunodeficiency disorders occur when T or B lymphocytes (special white blood cells) do not work properly. Immunodeficiency disorders may be inherited (genetically passed from parent to child) or acquired, an adverse effect to: another illness, such as HIV positive status or some malignancies; long-term use of certain medications, such as corticosteroids; chemotherapy treatments; or a manifestation of a splenectomy (the surgical removal of the spleen). Feedback: The immune system is the armed forces network that develops special forces, known as antibodies, produced by plasma cells in the blood to protect the body from pathogens and other invaders (antigens) that may disrupt proper function. In the previous section, you learned about the role that the different types of white blood cells play in guarding the good health of the body... your immune system. Researchers continue to study and learn more about the actual mechanisms in place, to employ in the development of more effective and efficient treatments when the body cannot fight alone. The integration of technology and the greater availability of genetic details supports these efforts to eliminate past and current illness and disease, and to fight off or prevent new conditions from evolving.

Immunodeficiency disorders are conditions when the patient's immune response is diminished or totally ineffective. Typically, immunodeficiency disorders occur when T or B lymphocytes (special white blood cells) do not work properly. Immunodeficiency disorders may be inherited (genetically passed from parent to child) or acquired, an adverse effect to: another illness, such as HIV positive status or some malignancies; long-term use of certain medications, such as corticosteroids; chemotherapy treatments; or a manifestation of a splenectomy (the surgical removal of the spleen). Learning Objective: 08.05 Topic: Disorders Involving the Immune System Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Basics! 1. Answer: disease, D56.0 Feedback: Hemoglobin H disease: disease, D56.0 D56.0: Index>disease>hemoglobin>H Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: purpura, D65 Feedback: Purpura fulminans: purpura, D65 D65: Index>purpura>fulminans Learning Objective: 08.01

Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: anemia, D51.0 Feedback: Anemia due to vitamin B12, intrinsic factor deficiency: anemia, D51.0 D51.0: Index>anemia>deficiency>vitamin B12>due to >intrinsic factor deficiency Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4. Answer: hematopoiesis, D70.4 Feedback: Cyclic hematopoiesis: hematopoiesis, D70.4 D70.4: Index>hematopoiesis, cyclic Learning Objective: 08.01 Learning Objective: 08.02

Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 5. Answer: pancytopenia, D61.810 Feedback: Antineoplastic chemotherapy induced pancytopenia: pancytopenia, D61.810 D61.810: Index>pancytopenia> Antineoplastic chemotherapy induced Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 6. Answer: thalassemia, D56.3 Feedback: Minor alpha thalassemia: thalassemia, D56.3 D56.3: Index>thalassemia>alpha>minor Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04

Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 7. Answer: hypoplasia, D61.9 Feedback: Medullary hypoplasia: hypoplasia, D61.9 D61.9: Index>hypoplasia>medullary Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 8. Answer: pseudoleukemia, D64.89 Feedback: Infantile pseudoleukemia: pseudoleukemia, D64.89 D64.89: Index>pseudoleukemia, infantile Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions

Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 9. Answer: deficiency, D66 Feedback: Deficiency factor VIII: deficiency, D66 D66: Index>deficiency>factor>VIII Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 10. Answer: neutropenia, D70.0 Feedback: Congenital neutropenia: neutropenia, D70.0 D70.0: Index>neutropenia>congenital Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 11. Answer: disease, D57.219 Feedback: Sickle-cell Hb-C with crisis Disease: disease, D57.219 D57.219: Index>disease>sickle-cell>Hb-C>with crisis Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 12. Answer: agranulocytosis, D70.3 Feedback: Agranulocytosis due to infection: agranulocytosis, D70.3 D70.3: Index>agranulocytosis>due to infection Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 13. Answer: syndrome, D59.30 Feedback: Hemolytic-uremic syndrome: syndrome, D59.30 D59.3: Index>syndrome>hemolytic-uremic Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 14. Answer: polycythemia, D75.1 Feedback: Polycythemia due to erythropoietin: polycythemia, D75.1 D75.1: Index>polycythemia>due to>erythropoietin Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy

Est Time: 1-3 minutes 15. Answer: Histiocytosis, D76.3 Feedback: Non-Langerhans cell histiocytosis: Histiocytosis, D76.3 D76.3: Index>histiocytosis>non-Langerhans cell Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes You Code It! Practice 1. Answer: D55.0 Feedback: D55.0: Index>Anemia>favism Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes

2. Answer: D58.2 Feedback: D58.2: Index>Disease>hemoglobin>C Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: Feedback: T52.1X1A, D61.2, Y92.63, Y99.0 T52.1X1A: Drug table>benzene>poisoning accidental>initial encounter D61.2: Index>Anemia>aplastic>due to>external agents NEC Y92.63: External cause index>place of occurrence>industrial and construction area> factory Y99.0: External cause index>status>civilian activity done for income or pay Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium

Est Time: 3-5 minutes 4. Answer: D68.62 Feedback: D68.62: Index>Syndrome>lupus anticoagulant Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: D76.1 Feedback: D76.1: Index>Lymphohistiocytosis>hemophagocytic Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: D81.810 Feedback: D81.810: Index>Deficiency>biotinidase

Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: Q87.2, D69.42 Feedback: Q87.2: Index>Thrombocytopenia>with absent of radius (TAR) D69.42: Index>Purpura>thrombocytopenia>congenital Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: D82.1 Feedback: D82.1: Index>Syndrome>Di George‘s Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03

Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: D55.21 Feedback: D55.21: Index>Anemia>pyruvate kinase deficiency Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: D72.810 Feedback: Index>Lymphocytopenia Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor

Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: A18.89, D63.8 Feedback: A18.89: Index>Anemia>tuberculous D63.8: Index>Anemia>due to chronic diseases classified elsewhere Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: N18.4, D63.1 Feedback: N18.4: Index>Disease>kidney>stage 4 D63.1: Index>Anemia>due to>chronic kidney disease Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs

Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: T80.410A Feedback: T80.410: Index>Complication>incompatibility>transfusion>Rh>acute>encounter Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: C91.10 Feedback: C91.10: Index>Leukemia> chronic lymphocytic, of B-cell type>NOS Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: B76.9, D63.8 Feedback: B76.9: Index>Anemia>hookworm D63.8: Index>Anemia>due to>chronic disease classified elsewhere NEC Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application Application 1: KRIESEL, BROOKE Answer: D50.9 Feedback: D50.9: Index>anemia>deficiency>iron>unspecified Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: LAKEMONT, CALIB Answer: D69.3 Feedback: D69.3: Index>Thrombocytopenia>idiopathic Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: FUENTES, ERIN Answer: C92.40 Feedback: C92.40: Index>leukemia>acute promyelocytic Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: FLOWERS, CATLYNNE Answer: D57.211, R50.81 Feedback: D57.211: Index>Disease>sickle-cell>Hb-C>with crisis>with>acute chest>syndrome R50.81: Index>Fever>due to>conditions classified elsewhere Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: ARNOLD, CAMERON Answer: D68.00 Feedback: D68.00: Index>Disease>Von Willebrand Learning Objective: 08.01 Learning Objective: 08.02 Learning Objective: 08.03 Learning Objective: 08.04 Learning Objective: 08.05 Topic: Reporting Blood Conditions Topic: Coagulation Defects and Other Hemorrhagic Conditions Topic: Conditions Related to Blood Types and the Rh Factor Topic: Disorders of White Blood Cells and Blood-Forming Organs Topic: Disorders Involving the Immune System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

Chapter 9 Coding Endocrine Conditions 2024 Compliant Learning Outcomes

LO 9.1 Identify the various disorders affecting the thyroid gland. LO 9.2 Evaluate the details about a diabetes mellitus diagnosis to determine the correct code. LO 9.3 Assess the relationship between diabetes mellitus and its manifestations. LO 9.4 Interpret the documentation related to the reporting of other endocrinologic diseases. LO 9.5 Identify the aspects of nutrition and weight required for accurate code determination. LO 9.6 Analyze the details related to metabolic disorder diagnoses to determine the correct code. Chapter Outline Learning Outcomes Key Terms Disorders of the Thyroid Gland Thyroid Gland Parathyroid Glands Hypothyroidism (Adults) Hyperthyroidism Grave’s Disease Thyroid Nodules Thyroiditis Other Disorders of the Thyroid Diabetes Mellitus Diabetic Manifestations Ophthalmic Manifestations Neurologic Manifestations Renal Manifestations Circulatory Manifestations Long-Term Drug Use Long-Term Insulin Use Long-Term Hypoglycemic Use Diabetes-Related Conditions

Hyperglycemia and Hypoglycemia Insulin Pumps Underdose of Insulin Overdose of Insulin Other Endocrine Gland Disorders Diabetes Insipidus Cushing’s Syndrome Postprocedural Endocrine System Complications Nutritional Deficiencies and Weight Factors Nutritional Deficiencies Obesity Body Mass Index Underweight Metabolic Disorders Cystic Fibrosis Lactose Intolerance Chapter Summary Chapter 9 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application

Chapter Overview

The endocrine system is a complex network of organs that, for the most part, produce hormones that ignite certain functions throughout the body. Metabolism and reproduction are the most well-known. The conditions affecting this system run the gambit from malignancy to lesions to abnormal function. The most common of all is diabetes mellitus. Diabetes mellitus is a very dangerous disease that affects as many as 16 million Americans. It is known as one of the leading causes of death by disease and frequently goes undiagnosed. This disease has four different forms of its etiology: type 1, type 2, gestational diabetes mellitus (GDM), and other specific types.

Diabetes affects both men and women equally. The risk of developing type 2 diabetes increases with other conditions including: obesity; lack of physical activity; history of GDM; hypertension; dyslipidemia; having a strong family history of diabetes; having an African American, Latino, or Native American origin; and/or increasing age. In many cases, drug therapy in addition to an appropriate diet and exercise regime may decrease some of these risks.

Discussion Activities 1.

Discuss the different types of diabetes mellitus. [Learning Outcome: 9.2]

Have students discuss the impact each type of diabetes may have on an individual’s health. Review the various code categories from which a diagnosis of diabetes may be reported. Discuss the diagnostic tests used to confirm, as well as impact on treatment.

2.

Describe the involvement of nutrition and weight in the health of the human body. [Learning Outcome: 9.5]

This discussion should include the various effects of good and bad nutrition and healthy weight on good health.

3.

When a patient is diagnosed with diabetic manifestations, how does that impact the codes used? [Learning Outcome: 9.3]

Diabetic manifestations are not unusual and can present a challenge to new coders. Support this discussion with the Official Guidelines, section 1.C, subsection 4a. Diabetes mellitus.

Additional Resources Endocrine Diseases (MedlinePlus): http://www.nlm.nih.gov/medlineplus/endocrinediseases.html Factors that Affect Endocrine Function (Hormone Health Network): http://www.hormone.org/hormones-and-health/the-endocrinesystem/factors-that-affect-endocrine-function Common Diseases of the Endocrine System: http://www.pamf.org/endocrinology/services/faqs.html Diabetes Mellitus (MedicineNet): http://www.medicinenet.com/diabetes_mellitus/article.htm Endocrine Diseases (MedlinePlus): http://www.nlm.nih.gov/medlineplus/endocrinediseases.html Diabetes (MedlinePlus): http://www.nlm.nih.gov/medlineplus/diabetes.html Thyroid Diseases (MedlinePlus): http://www.nlm.nih.gov/medlineplus/thyroiddiseases.html Grey‘s Anatomy Online: http://www.bartleby.com/107/ Stedman‘s Medical Dictionary: http://www.stedmans.com/

MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html American Medical Association: http://www.ama-assn.org American Hospital Association: http://www.aha.org American Health Information Management Association: http://www.ahima.org AAPC: http://www.aapc.com ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 9 Review Answer Key Let’s Check It! Terminology Answer: 1. O Type 2 DM 2. B Diabetes mellitus 3. D Gestational diabetes mellitus (GDM) 4. E Hyperglycemia 5. J Polydipsia 6. L Secondary DM 7. K Polyuria 8. C Dyslipidemia 9. F Hypoglycemia 10. H Hypothyroidism 11. N Type 1 DM 12. A Cushing‘s syndrome 13. I Parathyroid glands 14. M Thyroid gland 15. G Hypoglycemics Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minute Let’s Check It! Concepts 1.

Answer: B hyperglycemia Feedback: A patient with hyperglycemia is not diagnosed with diabetes. Hyperglycemia, just like hypoglycemia, is a separate condition.

Chronic hyperglycemia may impair one‘s resistance to infection, resulting in diabetic skin problems and urinary tract infections. A diabetic patient that has hypoglycemia may have administered too much insulin or antidiabetic medication. Learning Objective: 09.03 Topic: Diabetes-Related Conditions Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: C E11.21 Feedback: E11.21: Index>Diabetes>type 2>Kimmelsteil-Wilson disease. Learning Objective: 09.02 Topic: Diabetes Mellitus Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: D neurologic Feedback: Diabetic retinopathy, one of the leading causes of irreversible blindness, may be one of several types: • Background retinopathy: Blood vessel damage with no current vision problems • Maculopathy: Damage to the macula part of the eye, resulting in a considerable loss of vision • Proliferative retinopathy: A microvascular complication of diabetes where the small vessels of the eye become diseased as a result of diminishing oxygen • Other eye problems often suffered by diabetics include diabetic cataracts and macular edema. Learning Objective: 09.02 Topic: Diabetes Mellitus Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2

ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minutes 4. Answer: C who is pregnant Feedback: Gestational DM: When a woman is pregnant, the weight gain, along with the higher levels of estrogen and the increase of placental hormones, may retard the production of insulin. This is considered a temporary type of DM due to the fact that, typically, the problem with the pancreatic beta cells resolves itself after the baby is delivered. Report this with a code from the ICD-10-CM code subcategory O24.4 Gestational diabetes mellitus, with an additional character to report additional details.

Learning Objective: 09.02 Topic: Diabetes Mellitus Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minutes

5. Answer: D E10.9, E66.3, G60.1 Feedback: The correct codes for a patient with type 1 DM who is overweight and has been diagnosed with Refsum‘s disease are E10.9, Type 1 DM; E66.31, overweight; and G60.1 Refsum‘s disease. E10.9: Index>diabetes>type 1 E66.3: Index>overweight G60.1: Index>Refsum‘s disease Learning Objective: 09.05 Topic: Nutritional Deficiencies and Weight Factors Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: C T37.0X5A, E03.2 Feedback: The correct codes for drug-induced hypothyroidism are E03.2 and T37.0X5A. T379.0X5A: Drug table>sulfonamide>adverse effect>initial encounter. E03.2: Index>hypothyroidism>drug-induced.

See instructional note to Use additional code to identify the poisoning drug under E03.2 Learning Objective: 09.01 Topic: Disorders of the Thyroid Gland Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: A Hypothyroidism Feedback: Hypothyroidism is caused by an insufficient production of thyroid hormone (TH). When a patient has hypothyroidism, the thyroid converts energy more slowly than normal, resulting in an otherwise unexplained weight gain and fatigue. Learning Objective: 09.01 Topic: Disorders of the Thyroid Gland Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minutes 8. Answer: B Diabetes insipidus Feedback: Another type of diabetes that few people have heard of is diabetes insipidus (DI). DI is a disorder of water metabolism that is the result of an antidiuretic hormone (ADH) deficiency. Learning Objective: 09.04 Topic: Other Endocrine Gland Disorders Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minutes 9. Answer: C 30 and 38.9

Feedback: Obesity is a condition calculated as a body mass index of 30 to 38.9. Typically, a person becomes obese when more calories are consumed than expended. Learning Objective: 09.05 Topic: Nutritional Deficiencies and Weight Factors Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minutes 10. Answer: D All of these Feedback: The long list of metabolic diagnoses includes: • Acid lipase disease • Amyloidosis • Barth‘s syndrome • Central pontine myelinolysis • Farber‘s disease • G6PD deficiency • Gangliosidoses • Hunter‘s syndrome • Trimethylaminuria • Lesch-Nyhan syndrome • Lipid storage diseases • Metabolic myopathies • Mitochondrial myopathies • Mucopolysaccharidoses (MPS) • Mucolipidoses • Mucopolysaccharidoses • Type I glycogen storage disease • Pompe‘s disease • Urea cycle disorder • Hyperoxaluria • Oxalosis Learning Objective: 09.06 Topic: Metabolic Disorders Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minutes

Let’s Check It! Guidelines 1. Answer: combination, body system Feedback: I.C.4.a The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system. Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 2. Answer: E08-E13 Feedback: I.C.4.a Assign as many codes from categories E08 – E13 as needed to identify all of the associated conditions that the patient has. Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Understand CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 3. Answer: age, puberty Feedback: I.C.4.a.1 The age of a patient is not the sole determining factor, though most type 1 diabetics develop the condition before reaching puberty. Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 4. Answer: type, E11.Feedback: I.C.4.a.2 If the type of diabetes mellitus is not documented in the medical record the default is E11.-, Type 2 diabetes mellitus. Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors

Topic: Metabolic Disorders Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 5. Answer: T85.6, T38.3x6Feedback: I.C.4.a.5.a An underdose of insulin due to an insulin pump failure should be assigned to a code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, that specifies the type of pump malfunction, as the principal or first-listed code, followed by code T38.3x6-, Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs. Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 6. Answer: T85.6-, T38.3x1Feedback: I.C.4.a.5.b The principal or first-listed code for an encounter due to an insulin pump malfunction resulting in an overdose of insulin, should also be T85.6-, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, followed by code T38.3x1-, Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional). Learning Objective: 09.01 Learning Objective: 09.02

Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 7. Answer: E08, E09, E13 Feedback: I.C.4.a.6 Codes under categories E08, Diabetes mellitus due to underlying condition, E08, Drug or chemical induced diabetes mellitus, and E13, Other specified diabetes mellitus, identify complications/manifestations associated with secondary diabetes mellitus. Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 8. Answer: Z79

Feedback: I.C.4.a.6.a For patients with secondary diabetes mellitus who routinely use insulin or hypoglycemic drugs, or injectable non-insulin drugs, additional code(s) from category Z79 should be assigned to identify long-term (current) use of insulin or oral hypoglycemic drugs. Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 9. Answer: not Feedback: I.C.4.a.6.a Code Z79.4 should not be assigned if insulin is given temporarily to bring a patient‘s blood sugar under control during an encounter. Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 2 Medium Est Time: 1-3 minutes 10. Answer: E89.1 Feedback: I.C.4.b.i For postpancreatectomy diabetes mellitus (lack of insulin due to the surgical removal of all or part of the pancreas), assign code E89.1, Postprocedural hypoinsulinemia. Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes Let’s Check It! Rules and Regulations 1. Answer: Graves‘ disease (toxic diffuse goiter) is an autoimmune disorder. This malfunction of the immune system creates an antibody called thyroid stimulating immunoglobulin (TSI) that affixes itself to thyroid cells. TSI then accelerates the overproduction of the thyroid hormone. When you look up Grave‘s disease in the alphabet index you will be directed: Disease>Grave‘s – see hyperthyroidism, with goiter (diffuse). Feedback: Graves‘ disease (toxic diffuse goiter) is an autoimmune disorder. This malfunction of the immune system creates an antibody called thyroid stimulating immunoglobulin (TSI) that affixes itself to thyroid cells. TSI then accelerates the overproduction of the thyroid hormone. When you look up Grave‘s disease in the alphabet index you will be directed: Disease>Grave‘s – see hyperthyroidism, with goiter (diffuse). Learning Objective: 09.01 Topic: Disorders of the Thyroid Gland

Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: 

Type 1 DM: The malfunction of the pancreatic beta cells, resulting in no production of insulin naturally, is the underlying cause of type 1 (juvenile) diabetes mellitus, although there is no documented known etiology for idiopathic DM. Therapeutically, type 1 DM patients must administer insulin every day in addition to following specific diet and exercise programs. Implanted insulin pumps may be used for those requiring multiple dose regimens. This diagnosis will be reported from ICD-10-CM code category E10 with additional characters required to identify specific information about complications (manifestations).

Type 2 DM: In type 2 patients, the pancreatic beta cells do produce insulin; however, the glucose transport is ineffective, thereby failing to deliver the required amount to the rest of the body. Type 2 diabetics often suffer pathologic effects, including increased body fat (obesity), especially when the individual does not exercise regularly. Family history of DM, co-morbidities of hypertension or dyslipidemia, or a personal history of gestational DM will increase the likelihood of developing this condition. In addition, patients of African-American, Latino, or Native American heritage are found to have a high risk. Diet and exercise are the first level of treatment and may resolve the condition. However, oral antidiabetic medications, such as sulfonylureas, may be prescribed to stimulate pancreatic beta cell function if diet and exercise fail to show sufficient improvement. Some type 2 DM patients require the administration of insulin. A type 2 diagnosis will be reported from ICD10-CM code category E11 with additional characters required to identify specific information about complications (manifestations). Feedback:  Type 1 DM: The malfunction of the pancreatic beta cells, resulting in no production of insulin naturally, is the underlying cause of type 1 (juvenile) diabetes mellitus, although there is no documented known etiology for idiopathic DM. Therapeutically, type 1 DM patients must administer insulin every day in addition to following specific diet and exercise programs. Implanted insulin pumps may be used for those requiring multiple dose regimens. This diagnosis will be reported from ICD-10-CM code category E10 with additional characters required to identify specific information about complications (manifestations). 

Type 2 DM: In type 2 patients, the pancreatic beta cells do produce insulin; however, the glucose transport is ineffective, thereby failing to deliver the required amount to the rest of the body. Type 2 diabetics often suffer pathologic effects, including increased body fat (obesity), especially when the individual does not exercise regularly. Family history of DM, co-morbidities of hypertension or dyslipidemia, or a personal history of gestational DM will increase the likelihood of developing this condition. In addition, patients of African-American, Latino, or Native American heritage are found to have a high risk. Diet and exercise are the first level of treatment and may resolve the condition. However, oral antidiabetic medications, such as sulfonylureas, may be prescribed to stimulate pancreatic beta cell function if diet and exercise fail to show sufficient improvement. Some type 2 DM patients require the administration of insulin. A type 2 diagnosis will be reported from ICD10-CM code category E11 with additional characters required to identify specific information about complications (manifestations). Learning Objective: 09.02 Topic: Diabetes Mellitus Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 

3. Answer: Insulin Pumps Technology has provided patients with an easier and more controlled manner by which to get their insulin: an insulin pump. However, nothing is perfect, so there may be a concern with the patient as a result of the insulin pump not working correctly. Overdose of Insulin Patients with an insulin pump that malfunctions can dose with a higher quantity of insulin than prescribed by the attending physician. For such a case, you will use the following code: T85.614A Breakdown (mechanical) of insulin pump, initial encounter Follow that code with a poisoning code, for example: T38.3x1A Poisoning by insulin and oral hypoglycemia (antidiabetic) drugs, accidental (unintentional), initial encounter Follow that code with the appropriate diabetes mellitus code and any other appropriate codes, including the codes identifying the reaction or conditions caused by the overdose.

Feedback: Insulin Pumps Technology has provided patients with an easier and more controlled manner by which to get their insulin: an insulin pump. However, nothing is perfect, so there may be a concern with the patient as a result of the insulin pump not working correctly. Overdose of Insulin Patients with an insulin pump that malfunctions can dose with a higher quantity of insulin than prescribed by the attending physician. For such a case, you will use the following code: T85.614A Breakdown (mechanical) of insulin pump, initial encounter Follow that code with a poisoning code, for example: T38.3x1A Poisoning by insulin and oral hypoglycemia (antidiabetic) drugs, accidental (unintentional), initial encounter Follow that code with the appropriate diabetes mellitus code and any other appropriate codes, including the codes identifying the reaction or conditions caused by the overdose. Learning Objective: 09.03 Topic: Diabetes-Related Conditions Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: Cushing‘s Syndrome Cushing’s syndrome is caused by excessive production of corticotropin (ACTH) in the hypothalamus and too much secretion from the adenohypophysis (pituitary gland). This may be caused by a tumor in another organ affecting this process—possibly a bronchogenic tumor or a malignant neoplasm of the pancreas. Approximately 30% of such cases are the result of a benign neoplasm of the adrenal gland. Cushing‘s syndrome may cause diabetes mellitus, hypokalemia (low potassium in the blood), pathologic fractures, slow wound healing, hypertension, irritability, and other conditions. Lab tests for plasma steroid levels measured by 24-hour urine samples can be used to confirm a diagnosis of Cushing‘s syndrome. An adrenal tumor can be seen on an ultrasound, CT scan, or angiography, while MRI and CT scans can illuminate the presence of a pituitary tumor. Administration of radiation therapy, drug therapy with a medication such as aminoglutethimide, or surgery to remove the tumor can be successful to control or reverse the effects of Cushing‘s syndrome. ICD-10-CM code category

E24 Cushing‘s syndrome, requires an additional character to provide more specific information about the condition. Feedback: Cushing‘s Syndrome Cushing’s syndrome is caused by excessive production of corticotropin (ACTH) in the hypothalamus and too much secretion from the adenohypophysis (pituitary gland). This may be caused by a tumor in another organ affecting this process—possibly a bronchogenic tumor or a malignant neoplasm of the pancreas. Approximately 30% of such cases are the result of a benign neoplasm of the adrenal gland. Cushing‘s syndrome may cause diabetes mellitus, hypokalemia (low potassium in the blood), pathologic fractures, slow wound healing, hypertension, irritability, and other conditions. Lab tests for plasma steroid levels measured by 24-hour urine samples can be used to confirm a diagnosis of Cushing‘s syndrome. An adrenal tumor can be seen on an ultrasound, CT scan, or angiography, while MRI and CT scans can illuminate the presence of a pituitary tumor. Administration of radiation therapy, drug therapy with a medication such as aminoglutethimide, or surgery to remove the tumor can be successful to control or reverse the effects of Cushing‘s syndrome. ICD-10-CM code category E24 Cushing‘s syndrome, requires an additional character to provide more specific information about the condition. Learning Objective: 09.04 Topic: Other Endocrine Gland Disorders Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: Cystic Fibrosis Cystic fibrosis (CF) is a hereditary malfunction of the secretory glands. Many lay people think of this as a malfunction of the pulmonary system. However, as you can see by the code descriptions, the effects of this genetic condition reach to other body systems, as well. A defect in the CFTR gene causes the glands that produce mucus and sweat, resulting in the creation of thick, sticky mucus and very salty sweat, manifestations can be seen in the respiratory, digestive, reproductive systems, as well as other conditions. E84.0 Cystic fibrosis with pulmonary manifestations

Use additional code to identify any infectious organism present, such as Pseudomonas (B96.5) E84.11 Meconium ileus in cystic fibrosis E84.19 Cystic fibrosis with other intestinal manifestations E84.8 Cystic fibrosis with other manifestations Other manifestations, reported with E84.8 includes male neonates born without a vas deferens or females who may have an overproduction of mucus blocking the cervix. Dehydration may result due to the large loss of salt in the CF patient's perspiration, Clubbing and now bone density, both of which occur later in life. Feedback: Cystic Fibrosis Cystic fibrosis (CF) is a hereditary malfunction of the secretory glands. Many lay people think of this as a malfunction of the pulmonary system. However, as you can see by the code descriptions, the effects of this genetic condition reach to other body systems, as well. A defect in the CFTR gene causes the glands that produce mucus and sweat, resulting in the creation of thick, sticky mucus and very salty sweat, manifestations can be seen in the respiratory, digestive, reproductive systems, as well as other conditions. Cystic fibrosis with pulmonary manifestations E84.0 Use additional code to identify any infectious organism present, such as Pseudomonas (B96.5) E84.11 Meconium ileus in cystic fibrosis E84.19 Cystic fibrosis with other intestinal manifestations E84.8 Cystic fibrosis with other manifestations Other manifestations, reported with E84.8 includes male neonates born without a vas deferens or females who may have an overproduction of mucus blocking the cervix. Dehydration may result due to the large loss of salt in the CF patient's perspiration, Clubbing and now bone density, both of which occur later in life. Learning Objective: 09.06 Topic: Metabolic Disorders Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Basics

Answer: Cretin, E00.1 Feedback: Endemic hypothyroid cretinism: Cretin, E00.1 E00.1: Index>cretin>type>hypothyroid Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 2. Answer: Diabetes, E11.65 Feedback: Diabetes mellitus with hyperglycemia: Diabetes, E11.65 E11.65: Index>diabetes>type II>with>hyperglycemia Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes

3. Answer: Abscess, E06.0 Feedback: Abscess of the thyroid: Abscess, E06.0 E06.0: Index>abscess>thyroid Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 4. Answer: Disease, E74.01 Feedback: Type I Glycogen Storage Disease: Disease, E74.01 E74.01: Index>disease>glycogen storage>type I Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes

5. Answer: Disorder, E72.20 Feedback: Urea Cycle metabolism disorder: Disorder, E72.20 E72.20: Index>disorder>urea cycle metabolism Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 6. Answer: Nodules, E05.20 Feedback: Thyroid nodules with thyrotoxicosis: Nodules, E05.20 E05.20: Index>nodules>thyroid>with>thyrotoxicosis Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy

Est Time: 3-5 minutes 7. Answer: Disease, E06.3 Feedback: Hashimoto‘s Disease: Disease, E06.3 E06.3: Index>disease>Hashimoto‘s Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 8. Answer: Deficiency, E29.1 Feedback: 5-alpha-Reductase deficiency: Deficiency, E29.1 E29.1: Index>deficiency>5-alpha-Reductase Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 1 Easy Est Time: 3-5 minutes 9. Answer: Encephalopathy, E51.2 Feedback: Wernicke‘s encephalopathy: Encephalopathy, E51.2 E51.2: Index>encephalopathy> Wernicke‘s Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 10. Answer: Disease, E72.02 Feedback: Hartnup‘s disease: Disease, E72.02 E72.02: Index>disease>hartnup‘s Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 11. Answer: hyperlipoproteinemia, E78.00 Feedback: hyperlipoproteinemia: hyperlipoproteinemia, E78.00 E78.00: Index>hyperlipoproteinemia Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 12. Answer: Fibrosis, E84.19 Feedback: Cystic fibrosis with intestinal manifestations: Fibrosis, E84.19 E84.19: Index>fibrosis>cystic>with> intestinal manifestations Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 13. Answer: Acidosis, E87.29 Feedback: Respiratory acidosis: Acidosis, E87.29 E87.2: Index>acidosis>respiratory Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 14. Answer: Hypoparathyroidism, E89.2 Feedback: Postprocedural hypoparathyroidism: Hypoparathyroidism, E89.2 E89.2: Index> hypoparathyroidism>postprocedural Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 15. Answer: Syndrome, E88.810 Feedback: Dysmetabolic syndrome X: Syndrome, E88.810 E88.810: Index>syndrome>Dysmetabolic X Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes You Code It! Practice 1. Answer: E05.00 Feedback: E05.00: Index>Hyperthyroidism>with>goiter Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors

Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: E75.5 Feedback: E75.5: Index>Wolman‘s disease Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: E11.641 Feedback: E11.641: Index>Diabetes>type II>with>hypoglycemia>with coma Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: E83.01, H18.043 Feedback: E83.01: Index>Disease>Wilson‘s H18.043: Index>Ring>Kayser–Fleischer>bilaterally Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: E87.5 Feedback: Index>E87.5: Hyperkalemia Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors

Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: E10.52, I70.262 Feedback: E10.52: Index>Diabetes>type I>with>peripheral angiopathy>with gangrene I70.262: Index>Arteriosclerosis>extremities>leg>left>with>gangrene Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: E76.1 Feedback: E76.1: Index>Hunter‘s>syndrome Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders

Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: E73.9 Feedback: E73.9: Index>Intolerance>lactose Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: E72.03, H42 Feedback: E72.03: Index>Lowe‘s syndrome H42: Index>Glaucoma>in>lens disorder (secondary>lowe‘s syndrome) Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions

Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: O36.8130, O24.113, E11.9, Z3A.29 Feedback: O36.8130: Index>Pregnancy>complicated by>fetal>decreased movement>third trimester> unspecified O24.113: Index>Pregnancy>complicated by>diabetes>pre-existing>type II>third trimester E11.9: Index>Diabetes>type II>without complications Z3A.29: Index>Pregnancy>weeks of gestation>29 Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: E88.810, E66.8, Z68.35 Feedback: E88.810: Index>Dysmetabolic syndrome X E66.8: Index>Obesity Z68.35: Index>Body>Mass index>adult>35.4 Learning Objective: 09.01

Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: E89.1, E13.65, Z90.410, Z79.4, Z91.14 Feedback: E89.1: Index>Postpancreatectomy hyperglycemia E13.65: Index>Diabetes>specified type NEC>with>hyperglycemia Z90.410: Index>Absence>pancreas>acquired Z79.4: Index>Long-term drug>insulin Z91.14: Index>Noncompliance>medication regimen Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes

13. Answer: E80.4 Feedback: E80.4: Index>Gilbert‘s syndrome Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: E10.22, N18.4, Z99.2 Feedback: E10.22: Index>Diabetes>type I>with>chronic kidney disease N18.4: Index>Disease>kidney>chronic>stage 4 Z99.2: Index>Dependence>on>machine-renal dialysis Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium

Est Time: 3-5 minutes 15. Answer: E26.02, I10 Feedback: E26.02: Index>Aldosteronism>familial (type I) I10: Index>Hypertension>essential Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application Application 1: FUENTES, GILES Answer: E83.51 Feedback: E83.51: Index>Hypocalcemia Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: MOLINAZZI, JAMES Answer: E05.90, E09.9 Feedback: E05.90: Index>Hyperthyroidism E09.9: Index>Diabetes>due to underlying condition Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: CARTER, KIMBERLY Answer: Feedback: E11.3213, E11.22, N18.1, I13.0, I50.9, Z79.4 E11.3213: Index>Diabetes>type II>with>retinopathy>nonproliferative>mild>with macular edema>bilateral E11.22: Index>Diabetes>type II>with>chronic kidney disease N18.1: Index>Disease>kidney>chronic>stage 1 I130: Index> Hypertension>cardiorenal>with heart failure>with stage 1 through 4 chronic kidney disease I50.9: Index>Failure>heart>congestive Z79.4: Index>Long term drug therapy>insulin Learning Objective: 09.01 Learning Objective: 09.02

Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: WILLRODT, VICTORIA Answer: E10.628, H02.732 Feedback: E10.628: Index>Diabetes>type I>with>skin complications H02.732: Index>Vitiligo>eyelid>right>lower Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: HAWKINS, TYRONE Answer: E11.22, N18.6, Z99.2, Z79.4

Feedback: E11.22: Index>Diabetes>type II>with>chronic kidney disease N18.6: Index>Disease>renal>end stage Z99.2: Index>Dependence>machine>renal dialysis Z79.4: Long-term drug therapy>insulin Learning Objective: 09.01 Learning Objective: 09.02 Learning Objective: 09.03 Learning Objective: 09.04 Learning Objective: 09.05 Learning Objective: 09.06 Topic: Disorders of the Thyroid Gland Topic: Diabetes Mellitus Topic: Diabetes-Related Conditions Topic: Other Endocrine Gland Disorders Topic: Nutritional Deficiencies and Weight Factors Topic: Metabolic Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 10 Coding Mental, Behavioral, and Nervous Disorders 2024 Compliant Learning Outcomes

LO 10.1 Determine underlying conditions that affect mental health. LO 10.2 Distinguish mood and nonmood disorders. LO 10.3 Apply the guidelines for reporting nonpsychotic mental conditions. LO 10.4 Identify conditions affecting the central nervous system. LO 10.5 Interpret details regarding peripheral nervous system conditions into accurate codes. LO 10.6 Assess the diagnosis of pain and report it with accurate codes. Chapter Outline Learning Outcomes Key Terms Conditions That Affect Mental Health Mental Disorders due to Known Physiological Conditions Vascular Dementia Amnestic Disorder due to Known Physiological Condition Mood Disorder due to Known Physiological Condition

Personality and Behavioral Disorders due to Known Physiological Condition Mental and Behavioral Disorders due to Psychoactive Substance Use Reporting Alcohol- and Drug-Related Disorders In Remission Mood (Affective) and Non-mood (Psychotic) Disorders Mood (Affective) Disorders Bipolar Disorders Major Depressive Disorder Nonmood (Psychotic) Disorders Schizophrenia Schizoid Personality Disorder Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonpsychotic Mental Disorders Phobias Somatoform Disorders Stress-Related Disorders Physiological Conditions Affecting the Central Nervous System Inflammatory Conditions of the Central Nervous System Hereditary and Degenerative Diseases of the Central Nervous System Hydrocephalus Migraine Headaches Physiological Conditions Affecting the Peripheral Nervous System Dominant and Nondominant Sides Carpal Tunnel Syndrome Plexus Disorders Complex Regional Pain Syndrome Pain Management Reporting Pain Separately Postprocedural Pain Site-Specific Pain Codes Sequencing Pain Codes with Other Codes Chapter Summary Chapter 10 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Basics

You Code It! Practice You Code It! Application

Chapter Overview Mental and behavioral disorders have long been a mystery to the average person, and the lack of understanding has fed fear of patients with these disorders. The dysfunction of a person’s brain is often the result of many of the same things that cause other bodily health concerns, including genetics, congenital anomalies, traumatic injury, or the invasion of a pathogen. Any of these, along with other conditions and circumstances, have the ability to impact the health and function of the brain. Scientific research has evidenced shared signs and symptoms between psychiatric illness and neurologic illness. The accepted understanding of mental illness is a condition that negatively affects an individual’s thoughts, emotions, behaviors, ability to maintain effective social interactions, and ability to appropriately carry out the activities of daily living. Due to an increase in available care, more patients are receiving treatment for mental and behavioral disorders. Therefore, it is important for professional coding specialists to understand both psychological and physiological concerns. Through education and understanding, these patients can receive treatment and their providers can receive accurate reimbursement. The most obvious function of the nervous system is to enable an individual to feel things—sensory touch and input. With this function, you are able to feel hot and cold, soft and hard, pleasure and pain. In addition to enabling the sense of feeling, the body’s nervous system is also involved in the stimulation required for the musculoskeletal system to work. It is the brain that instructs muscles to contract so that you can sit up, cut a piece of paper, or walk down the street. Bundles of nerve fibers that instruct the activities of the cardiac muscles and smooth muscles, as well as gland function, are known as the autonomic nervous system. The nervous system is also responsible for the brain’s ability to think, understand, remember, and perform other mental activities. This is why some mental disorders, such as dementia and epilepsy, are treated by neurologists. Many different circumstances and situations can be the cause of malfunction anywhere in the nervous system. As with any other organ system or diagnosis, professional coding specialists should never assume. Everything you need to report these conditions accurately is in the physician’s documentation. If it is not, you must query the physician.

Discussion Activities 1. Mental Disorders due to a Known Physiological Condition [Learning Outcome: 10.1] There are many diseases that can actually cause a mental or behavioral disorder. Identify a disease that has known mental manifestations. Review the signs and symptoms of the manifestation and include the code or codes to accurately report the diagnosis.

a. Illnesses include: brain infarction, Parkinsonism, vascular stenosis, trauma, Korsakov’s syndrome, and hormonal imbalances.

2. Dominant and Nondominant Sides [Learning Outcome: 10.5] Are you right-handed or left-handed? When neurologic disease or injury affects the use of one-side of the body, this detail is important to treatment plans and support services required by the patient. Therefore, it must be reported by the code. Discuss the differences between monoplegia and hemiplegia and what details you need to abstract from the documentation to determine the correct code. Identify the Official Guideline that provides direction to the proper way to report this specific.

a. Official Guidelines section 1.C.6. Subsection a. Dominant/nondominant side.

Additional Resources Mental Disorders (MedlinePlus): http://www.nlm.nih.gov/medlineplus/mentaldisorders.html Mental Disorders (World Health Organization): http://www.who.int/topics/mental_disorders/en/ Diseases and Conditions Mental Illness (Mayo Clinic): http://www.mayoclinic.org/diseases-conditions/mentalillness/basics/definition/con-20033813 Grey‘s Anatomy Online: http://www.bartleby.com/107/ Stedman‘s Medical Dictionary: http://www.stedmans.com/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html American Medical Association: http://www.ama-assn.org American Hospital Association: http://www.aha.org American Health Information Management Association: http://www.ahima.org AAPC: http://www.aapc.com ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 10 Review Answer Key Let’s Check It! Terminology Answer: 1. E Depressive 2. D Dependence 3. F Manic 4. B Anxiety 5. I Somatoform disorders 6. J Use 7. C Behavioral disturbance 8. G Phobia 9. A Abuse 10. H Schizophrenia

Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts 1. Answer: C psychological and physiological Feedback: When a patient is diagnosed with an alcohol- or drug-related disorder, the diagnosis is often more complex, as such conditions are susceptible to both psychological and physiological signs, symptoms, manifestations, and co-morbidities. Learning Objective: 10.01 Topic: Conditions That Affect Mental Health Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: D hallucinations Feedback: Mood disorders include depression, apathy, and euphoria. Hallucinations are psychotic symptoms. Learning Objective: 10.02 Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

3. Answer: C dependent on Feedback: Use is consumption of a substance without significant clinical manifestations Abuse is the ongoing, regular consumption of a substance with resulting clinical manifestations. Ongoing, regular consumption of a substance with resulting significant clinical manifestations and a dramatic decrease in the effect of the substance with continued use, therefore requiring an increased quantity of the substance to achieve intoxication. In addition, the patient will require continued consumption of the substance to avoid withdrawal symptoms and other serious behavioral effects, occurring at any time in the same 12-month period. Depressive is an emotional state that includes sadness, hopelessness, and gloom. Learning Objective: 10.01 Topic: Conditions That Affect Mental Health Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 4. Answer: C Hypochondriacal disorder Feedback: Hypochondriacal disorder is an example of a somatoform disorder Panic disorder is an example of a phobia disorder Bipolar disorder is an example of a mood disorder Schizophreniform disorder is an example of schizophrenia Learning Objective: 10.03 Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: B F31.2 Feedback: F31: Bipolar disorder F31.2: Index>Bipolar disorder, current episode, manic, severe, with psychotic features

F31.4: Index>Bipolar disorder, current episode, depressed, severe, without psychotic features F31.5: Index>Bipolar disorder, current episode, depressed, severe, with psychotic feature Learning Objective: 10.02 Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 6. Answer: C disease of the CNS Feedback: Some nervous system conditions affect the function of the CNS are linked to genetics or degeneration but not trauma. The patient may have a condition that is well known, such as Alzheimer‘s disease or dementia, or a lesser-known condition such as Parkinsonism or Huntington‘s chorea. Learning Objective: 10.04 Topic: Physiological Conditions Affecting the Central Nervous System Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 7. Answer: B tension headaches Feedback: The official guidelines state that if the pain is not specifically documented as acute or chronic, it should not be reported separately. The exceptions to this guideline include: Post-thoracotomy pain Post procedural pain Neoplasm-related pain Central pain syndrome In these four situations, the code from category G89 should be reported in addition to any other conditions related to the encounter. Learning Objective: 10.04 Topic: Physiological Conditions Affecting the Central Nervous System Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a

CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 8. Answer: C Post-traumatic stress disorder Feedback: Post-traumatic stress disorder (PTSD) is a condition in which a horrible experience leaves a lasting imprint on the patient‘s sense of danger. Learning Objective: 10.03 Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 9. Answer: A brachial Feedback: Four nerve plexuses are the branches from the spinal cord off into the peripheral nerve network:  The cervical plexus branches nerves to the head, neck, and shoulder.  The brachial plexus branches nerves to the chest, shoulders, upper

arms, forearms, and hands. The lumbar plexus branches nerves to the back, abdomen, groin, thighs, knees, and calves.  The sacral plexus branches nerves to the pelvis, buttocks, genitals, thighs, calves, and feet. Learning Objective: 10.05 Topic: Physiological Conditions Affecting the Peripheral Nervous System Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 

10. Answer: D Why was the encounter necessary? Feedback: To determine the proper sequencing of a code from category G89 with codes for site-specific pain or underlying conditions, the first question to be answered from the documentation is Why was this encounter necessary? If the answer is for pain management, the code from category G89 should be first-listed or the principal diagnosis reported. If the encounter is for any other

reason and the attention to pain management is secondary to the purpose for the encounter, then the first-listed or principal diagnosis code would report that other reason and the code from category G89 would be reported afterward. Learning Objective: 10.06 Topic: Pain Management Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute Let’s Check It! Guidelines: 1. Answer: F45.41, psychological Feedback: 1. I.C.5.a: Assign code F45.41, for pain that is exclusively related to psychological disorders. As indicated by the Excludes 1 note under category G89, a code from category G89 should not be assigned with code F45.41. Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 2. Answer: F45.42, G89 Feedback: 2. I.C.5.a: Code F45.42, Pain disorders with related psychological factors, should be used with a code from category G89, Pain, not elsewhere classified, if there is

documentation of a psychological component for a patient with acute or chronic pain. Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 3. Answer: codes, documentation Feedback: I.C.5.b.1: The appropriate codes for ―in remission‖ are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting). Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 2 Medium Est Time: 1-3 minutes 4. Answer: one Feedback: I.C.5.b.2: When the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy: If both use and abuse are documented, assign only the code for abuse If both abuse and dependence are documented, assign only the code for dependence If use, abuse and dependence are all documented, assign only the code for dependence If both use and dependence are documented, assign only the code for dependence. Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 5. Answer: associated, substance related, relationship Feedback: I.C.5.b.3: As with all other unspecified diagnoses, the codes for unspecified psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-m F18.9, F19.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). These codes are to be used only when the psychoactive substance use is associated with a substance related disorder (chapter 5 disorders such as sexual dysfunction, sleep disorder, or a mental or behavioral disorder) or medical condition, and such a relationship is documented by the provider.

Learning Objective: 10.01

Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 6. Answer: pain Feedback: I.C.6.b.1 Codes in category G89, Pain, not elsewhere classified, may be used in conjunction with codes from other categories and chapters to provide more detail about acute or chronic pain and neoplasm-related pain, unless otherwise indicated below. Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes

7. Answer: default, acute Feedback: I.C.6.b.3 The default for post-thoracotomy and other postoperative pain not specified as acute or chronic is the code for the acute form. Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 8. Answer: G89.2 Feedback: I.C.6.b.4 Chronic pain is classified to subcategory G89.2. Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 9. Answer: G89.3, cancer Feedback: I.C.6.b.5 Code G89.3 is assigned to pain documented as being related, associated or due to cancer, primary or secondary malignancy, or tumor. Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 10. Answer: (G89.0), (G89.4), only Feedback: I.C.6.b.6 Central pain syndrome (G89.0) and chronic pain syndrome (G89.4) are different than the term ―chronic pain,‖ and therefore codes should only be used when the provider has specifically documented this condition. Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders

Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes Let’s Check It! Rules and Regulations 1. Answer: Use is the consumption of a substance without significant clinical manifestations Abuse is the ongoing, regular consumption of a substance with resulting clinical manifestations. Dependence is the ongoing, regular consumption of a substance with resulting significant clinical manifestations, and a dramatic decrease in the effect of the substance with continued use, therefore requiring an increased quantity of the substance to achieve intoxication. Feedback: Use is the consumption of a substance without significant clinical manifestations Abuse is the ongoing, regular consumption of a substance with resulting clinical manifestations. Dependence is the ongoing, regular consumption of a substance with resulting significant clinical manifestations, and a dramatic decrease in the effect of the substance with continued use, therefore requiring an increased quantity of the substance to achieve intoxication. Learning Objective: 10.01 Topic: Conditions That Affect Mental Health Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: Patients with schizoid personality disorder exhibit a limited range of emotions and an aversion to social relationships and personal interactions. These patients have little-to-no interest in sex and are indifferent to both praise and criticism. Overall, these patients have a flat affect.

Feedback: Patients with schizoid personality disorder exhibit a limited range of emotions and an aversion to social relationships and personal interactions. These patients have little-to-no interest in sex and are indifferent to both praise and criticism. Overall, these patients have a flat affect. Learning Objective: 10.02 Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: A phobia is an irrational and excessive fear of an object, activity, or situation. Feedback: A phobia is an irrational and excessive fear of an object, activity, or situation. Learning Objective: 10.03 Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: Inflammatory-Bacteria and viruses can invade the nervous system and cause infection, malfunction, and in some cases, death. Examples include encephalitis (inflammation of the brain tissue), myelitis (inflammation of the spinal cord), intracranial abscess, and the most well known condition, meningitis. Hereditary - Some nervous system conditions affect the function of the CNS and are linked to genetics or degeneration. Some examples would be Alzheimer‘s disease, dementia, Parkinsonism and Huntington‘s chorea. Feedback: Inflammatory-Bacteria and viruses can invade the nervous system and cause infection, malfunction, and in some cases, death. Examples include encephalitis (inflammation of the brain tissue), myelitis (inflammation of the spinal cord), intracranial abscess, and the most well known condition, meningitis.

Hereditary - Some nervous system conditions affect the function of the CNS and are linked to genetics or degeneration. Some examples would be Alzheimer‘s disease, dementia, Parkinsonism and Huntington‘s chorea. Learning Objective: 10.04 Topic: Physiological Conditions Affecting the Central Nervous System Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: Disorders that effect the peripheral nervous system may interfere with only one nerve, or multiple nerves. Dominant and Nondominant Sides Are you right-handed? If so, the right side of your body is considered your dominant side. Individuals who are left-handed have the left side of their bodies considered the dominant side. Then there are those who are ambidextrous (use both hands equally). Patients suffering with hemiplegia (paralysis of one side of the body) or hemiparesis (weakness of one side of the body)—code category G81—will need documentation of whether the dominant side or nondominant side is affected. The same is required for a patient diagnosed with monoplegia (paralysis of one extremity, e.g., one arm or one leg)—code category G83. You may have no memory of a physician ever asking you whether you are right- or left-handed—I don‘t. While neurologists are trained to consider this, you may find this detail missing from the documentation. For such cases, querying the physician may not help because he or she may not know. ICD10-CM Official Guidelines are here to help you determine the correct code when the affected (weakened or paralyzed) side is documented yet there is no indication of whether or not this is the patient‘s dominant side. The guidelines direct you: • Documentation states right side is affected—report as dominant. • Documentation states left side is affected—report as nondominant. For those patients documented to be ambidextrous, whichever side is documented as affected should be reported as the patient‘s dominant side. Feedback: Disorders that effect the peripheral nervous system may interfere with only one nerve, or multiple nerves. Dominant and Nondominant Sides Are you right-handed? If so, the right side of your body is considered your dominant side. Individuals who are left-handed have the left side of their bodies considered the dominant side. Then there are those who are ambidextrous (use both hands equally).

Patients suffering with hemiplegia (paralysis of one side of the body) or hemiparesis (weakness of one side of the body)—code category G81—will need documentation of whether the dominant side or nondominant side is affected. The same is required for a patient diagnosed with monoplegia (paralysis of one extremity, e.g., one arm or one leg)—code category G83. You may have no memory of a physician ever asking you whether you are right- or left-handed—I don‘t. While neurologists are trained to consider this, you may find this detail missing from the documentation. For such cases, querying the physician may not help because he or she may not know. ICD10-CM Official Guidelines are here to help you determine the correct code when the affected (weakened or paralyzed) side is documented yet there is no indication of whether or not this is the patient‘s dominant side. The guidelines direct you: • Documentation states right side is affected—report as dominant. • Documentation states left side is affected—report as nondominant. For those patients documented to be ambidextrous, whichever side is documented as affected should be reported as the patient‘s dominant side. Learning Objective: 10.05 Topic: Physiological Conditions Affecting the Peripheral Nervous System Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Basics: 1. Answer: Dependence, F17.200 Feedback: Nicotine dependence: Dependence, F17.200 F17.200: Index>dependence>nicotine Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: Disorder, F41.1 Feedback: Generalized anxiety disorder: Disorder, F41.1 F41.1: Index>disorder>anxiety>generalized Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: Dementia, F01.50 Feedback: Vascular dementia: Dementia, F01.50 F01.50: Index>dementia>vascular Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System

Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4. Answer: Impairment, G31.84 Feedback: Mild cognitive impairment: Impairment, G31.84 G31.84: Index>impairment>cognitive, mild, so stated Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 5. Answer: Abuse, F14.10 Feedback: Cocaine abuse: Abuse, F14.10 F14.10: Index>abuse>drug>cocaine Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders

Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 6. Answer: Disorder, F25.0 Feedback: Schizoaffective manic type disorder: Disorder, F25.0 F25.0: Index>disorder>schizoaffective>manic type Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 7. Answer: Delirium, F05 Feedback: Delirium with multiple etiologies: Delirium, F05 F05: Index>delirium>due to>multiple etiologies Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05

Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 8. Answer: Autism, F84.0 Feedback: Infantile autism: Autism, F84.0 F84.0: Index>autism>infantile Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 9. Answer: Meningitis, G00.8 Feedback: Bacterial meningitis, E coli: Meningitis, G00.8 G00.8: Index>meningitis>bacterial>e coli Learning Objective: 10.01 Learning Objective: 10.02

Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 10. Answer: Encephalitis, G04.00 Feedback: Acute disseminated encephalitis: Encephalitis, G04.00 G04.00: Index>encephalitis>acute>disseminated Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 11. Answer: Ataxia, G11.10 Feedback: Early-onset cerebellar ataxia: Ataxia, G11.10

G11.10: Index>ataxia>cerebellar>early-onset Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 12. Answer: Sclerosis, G12.21 Feedback: Amyotrophic lateral sclerosis: Sclerosis, G12.21 G12.21: Index>sclerosis>amyotrophic lateral Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes

13. Answer: Parkinsonism, G21.3 Feedback: Postencephalitic Parkinsonism: Parkinsonism, G21.3 G21.3: Index>parkinsonism>postencephalitic Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 14. Answer: Epilepsy, G40.309 Feedback: Generalized idiopathic epilepsy: Epilepsy, G40.309 G40.309: Index>epilepsy>generalized>idiopathic Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 1 Easy Est Time: 1-3 minutes 15. Answer: Palsy, G80.3 Feedback: Congenital dystonic cerebral palsy: Palsy, G80.3 G80.3: Index>palsy>cerebral>dystonic Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes You Code It! Practice 1. Answer: F11.20 Feedback: F11.20: Index>Dependence>drug>opioid Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: F98.3 Feedback: F98.3: Index>Pica>infant or child Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: F22 Feedback: F22: Index>Paranoid>reaction>chronic Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System

Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: F52.4 Feedback: F52.4: Index>Ejaculation>premature Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: F20.2 Feedback: F20.2: Index>Schizophrenia>catatonic Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System

Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: F40.231 Feedback: F40.231: Index>Phobia>specific>injection Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: F50.01 Feedback: F50.01: Index>Anorexia>nervosa>restricting type Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders

Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: B56.1, G02 Feedback: B56.1: Index>Trypanosomiasis>African>by trypanosome brucei>rhodesiense G02: Index>Meningitis>in (due to)>African trypanosomiasis Be careful here the type of African trypanosomiasis is documented as rhodesiense Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: G10 Feedback: G10: Index>Chorea>Huntington‘s Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05

Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: G12.0 Feedback: G12.0: Index>Atrophy>muscular>spinal>infantile, type I (WerdnigHoffman) Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: G25.3 Feedback: G25.3: Index>Myoclonus>palatal Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03

Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: G37.3 Feedback: G37.3: Index>Myelitis>transverse Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: G40.A09 Feedback: G40.A09: Index>Epilepsy>juvenile absence>not intractable>without status epilepticus

Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: G47.13 Feedback: G47.13: Index>Syndrome>Kleine-levin Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: G56.22

Feedback: G56.22: Index>Palsy>ulnar nerve>left Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application Application 1: PORTER, KELSEY Answer: F42.9 Feedback: F42.9: Index>Disorder>obsessive-compulsive>unspecified Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

Application 2: MYRICK, JULIE Answer: F41.0, E53.8 Feedback: F41.0: Index>Disorder>panic E53.8: Index>Deficiency>vitamin>B12 Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: FALCONE, ANTONIO Answer: F33.1, R45.851 Feedback: F33.1: Index>Disorder>depressive>recurrent>current episode>moderate R45.851: Index>ideation>suicide Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: LYNCH, VICTOR Answer: G93.7 Feedback: G93.7: Index>Reye‘s syndrome Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: YAN, MARANDA Answer: G35 Feedback: G35: Index>Sclerosis>multiple Learning Objective: 10.01 Learning Objective: 10.02 Learning Objective: 10.03 Learning Objective: 10.04 Learning Objective: 10.05 Learning Objective: 10.06 Topic: Conditions That Affect Mental Health Topic: Mood (Affective) and Nonmood (Psychotic) Disorders Topic: Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonspychotic Mental Disorders

Topic: Physiological Conditions Affecting the Central Nervous System Topic: Physiological Conditions Affecting the Peripheral Nervous System Topic: Pain Management Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 11 Coding Conditions of the Optical and Auditory Systems 2024 Compliant Learning Outcomes

LO 11.1 Identify conditions affecting the external eye. LO 11.2 Interpret the details documented about diseases of the internal optical system to report accurate code. LO 11.3 Determine the accurate code to report other conditions of the eye. LO 11.4 Abstract documentation accurately to report conditions affecting the auditory system. LO 11.5 Enumerate the causes, signs, and symptoms of hearing loss. Chapter Outline Learning Outcomes Key Terms Diseases of the External Optical System The Exterior of the Eye Blepharitis Exophthalmic Conditions Disorders of the Lacrimal Apparatus Dacryocystitis Diseases of the Internal Optical System Disorders of the Conjunctiva Disorders of the Sclera, Cornea, Iris, and Ciliary Body Disorders of the Lens Disorders of the Choroid and Retina The Uveal Tract The Retina Other Conditions Affecting the Eyes Glaucoma

Diabetic Retinopathy Hypertensive Retinopathy Dysfunctions of the Auditory System Auditory Diseases Causes, Signs, and Symptoms of Hearing Loss Signs and Symptoms of Hearing Loss Genetics and Congenital Anomalies Causing Hearing Loss Psychogenic (Hysterical) Hearing Loss Idiopathic Causes of Hearing Loss Traumatic (External) Causes of Hearing Loss Sounds Levels Causing Hearing Loss Chapter Summary Chapter 11 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application

Chapter Overview One of the five senses, vision is involved in virtually every aspect of one’s life. Loss of sight, or even the reduction of vision, has both social and economic impact on the patient and his or her family. In the United States, it is estimated that 14 million people aged 12 and over have some type of visual impairment, and about 61 million adults are believed to be at high risk for acute vision loss. This incredible complex organ system captures light and transmits it via interactive anatomical sites to the optic nerve and into the brain for evaluation and interpretation. Even though the skull protects the optical system, it is still susceptible to the invasions of pathogens (bacteria, viruses, fungi); can be damaged by trauma; and can be impacted by other environmental issues, such as UV light rays from the sun. The mechanics of the auditory system—enabling the ability to hear sounds— is not as complex as that of the optical system, but it is important, nonetheless. When an individual suffers from hearing loss or deafness, it can impede the ability to communicate with others. The auditory (hearing) system enables the human body to hear—one of only two senses that have their own organ systems. The auditory system passes along sound vibrations captured by the external ear, through the middle ear and the inner ear, to the cerebrum for interpretation.

Discussion Activities 1. Diseases of the Optical System [Learning Outcome: 11.3] Identify one disease that effect the optical system, list the integral signs and symptoms, and the standard of care for treatment. Include the correct code or codes used to accurately report this diagnosis. No repeats.

2. Glaucoma [Learning Outcome: 11.3] a. Describe the differences between open-angle and closed-angle glaucoma. b. Explain the differences between mild, moderate, and severe stages of glaucoma. What are the valid reasons for reporting “indeterminate” stage? What details do you need to abstract from the documentation to determine the correct code?

a. Open-angle glaucoma typically develops slowly over time. It is not painful and often has no other signs or symptoms until the disease has progressed significantly. Treatment is usually either medication or surgical treatment to reduce pressure in the eye. Closed-angle glaucoma will cause the patient to feel sudden eye pain, notice redness, and suffer nausea and vomiting. The sudden increase in intraocular pressure may also exhibit other signs and symptoms. This is considered a medical emergency.

b. Mild or early-stage glaucoma: defined as optic nerve abnormalities consistent with glaucoma but no visual field abnormalities on any white-on-white visual field test, or abnormalities present only on short-wavelength automated perimetry or frequencydoubling perimetry) Moderate-stage glaucoma: optic nerve abnormalities consistent with glaucoma and glaucomatous visual field abnormalities in one hemifield, and not within 5 degrees of fixation) Severe-stage glaucoma also known as advanced-stage glaucoma or end-stage glaucoma (optic nerve abnormalities consistent with glaucoma and glaucomatous visual field abnormalities in both hemifields, and/or loss within 5 degrees of fixation in at least one hemifield) Indeterminate (visual fields not performed yet, or patient incapable of visual field testing, or unreliable/uninterpretable visual field testing) 3. Signs and Symptoms of Hearing Loss [Learning Outcome: 11.4] Identify the signs and symptoms integral to hearing loss and explain the impact on activities and quality of life for the patient.

Students should not solely focus on the elderly. Patients lose hearing capabilities throughout their lives.

Additional Resources Eye Diseases (MedlinePlus): http://www.nlm.nih.gov/medlineplus/eyediseases.html Common Eye Disorders (Centers for Disease Control and Prevention): http://www.cdc.gov/visionhealth/basic_information/eye_disorders.htm Common Eye Conditions, slide show (MedicineNet.com): http://www.medicinenet.com/eye_diseases_pictures_slideshow/article.ht m Grey‘s Anatomy Online: http://www.bartleby.com/117/ Stedman‘s Medical Dictionary: http://www.stedmans.com/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html American Medical Association: http://www.ama-assn.org American Hospital Association: http://www.aha.org American Health Information Management Association: http://www.ahima.org AAPC: http://www.aapc.com ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 11 Review Answer Key Let’s Check It! Terminology Part I Answer: 1. H Retina 2. I Rod 3. B Cones 4. J Sclera 5. C Cornea 6. A Choroid 7. E Lens 8. G Pupil 9. F Orbit 10. D Iris Learning Objective: 11.01 Learning Objective: 11.02 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a

CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part II Answer: 1. J Palpebrae 2. G Meibomian glands 3. C Ciliary body 4. L Vitreous chamber 5. E Glands of Zeis 6. F Lacrimal apparatus 7. I Palpebral conjunctiva 8. A Accommodation 9. H Moll‘s glands 10. D Extraocular muscles 11. B Bulbar conjunctiva 12. K Uveal tract Learning Objective: 11.01 Learning Objective: 11.02 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part III Answer: 1. A Blepharitis 2. I Retinopathy 3. H Retinal detachment 4. F Keratitis 5. G Proptosis 6. B Conjunctivitis 7. D Dacryocystitis 8. E Glaucoma 9. C Corneal dystrophy Learning Objective: 11.01 Learning Objective: 11.02 Learning Ojective: 11.03

Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: B conjunctiva Feedback: There are five layers that make up the cornea: • Epithelium: the location of sensory nerves. • Bowman‘s membrane: the location of epithelial cells. • Stroma: the supporting tissue that makes up 90% of the corneal structure. • Descement‘s membrane: elastic fibers. • Endothelium: cells that help to maintain proper hydration of the cornea to keep it moist. Learning Objective: 11.01 Topic: Diseases of the External Optical System Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: A lacrimal gland Feedback: Tears are created in the main lacrimal gland and then flow through several excretory ducts, pass through the canaliculi and the lacrimal sac, and continue down the nasolacrimal duct into the nasal cavity—the nose. This is why when you cry, your nose runs. Learning Objective: 11.01 Topic: Diseases of the External Optical System Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1

Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: C Conjunctivitis Feedback: Conjunctivitis, commonly known as pink eye, actually refers to an inflammation of the conjunctiva of the eye. The most common signs and symptoms include swelling, itching, burning, and redness of the conjunctiva as well as the palpebral conjunctiva (lining of the eyelids).

Learning Objective: 11.02 Topic: Diseases of the Internal Optical System Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

4. Answer: D extraocular Feedback: Extraocular muscles are the muscles that control the eye. Learning Objective: 11.02 Topic: Diseases of the Internal Optical System Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: C H40.232 Feedback: H40.232: Glaucoma>angle-closure>intermittent>left Learning Objective: 11.03 Topic: Other Conditions Affecting the Eyes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: D headaches

Feedback: Diabetic Retinopathy Patients diagnosed with diabetes mellitus are at risk for ophthalmic manifestations of their improper glucose levels. Diabetic retinopathy is the most common; it is a condition that causes damage to the tiny blood vessels inside the retina (retina + -pathy = disease). Signs and symptoms include:  Blurry or double vision.  Rings around lights.  Flashing lights.  Blank spots.  Dark or floating spots (commonly known as floaters).  Pain in one or both eyes.  Sensation of pressure in one or both eyes.  Difficulty in seeing things peripherally (out of the corners of the eyes).  Macular edema occurs when fluid and protein deposits collect on or beneath the macula (a central area of the retina), resulting in swelling (edema). The swelling then causes the macula to thicken, distorting the person‘s central vision. When diagnosis and treatment are implemented in the early stages, vision loss can be reduced. Therefore, individuals with diabetes mellitus are encouraged to get regular eye exams. Diabetic retinopathy is one of the leading causes of blindness. Learning Objective: 11.03 Topic: Other Conditions Affecting the Eyes Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 7. Answer: C Endolymphatic hydrops Feedback: Endolymphatic hydrops (Méniere‘s disease) is a dysfunction of the labyrinth (semicircular canals). Signs and symptoms include vertigo, sensorineural hearing loss, as well as tinnitus. Learning Objective: 11.04 Topic: Dysfunctions of the Auditory System Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 8.

Answer: A labyrinthitis Feedback: Labyrinthitis is an infection within the inner ear's labyrinth. The most evident symptom is incapacitating vertigo, that may last as long as five days. Learning Objective: 11.04 Topic: Dysfunctions of the Auditory System Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 9. Answer: D conductive hearing loss Feedback: Cerumen (earwax) serves an important function within the ear canal. It protects the skin of the ear canal; protects the middle ear from bacteria, fungi, insects, and water; and enables cleaning and lubrication. However, too much cerumen can build up in the canal and form an obstruction, blocking the entrance of sound waves and causing sudden conductive hearing loss. Learning Objective: 11.05 Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 10. Answer: C 56 to 70 dB Feedback: Indication of Hearing Loss Hearing Threshold (dB) Normal hearing 0–20 Mild hearing loss 21–40 Moderate hearing loss 41–55 Moderately severe hearing loss 56–70 Severe hearing loss 71–90 Profound hearing loss 91 and above Learning Objective: 11.05 Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Remember

CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Guidelines 1. Answer: H40, glaucoma Feedback: I.C.7.a.1 Assign as many codes from category H40, Glaucoma, as needed to identify the type of glaucoma, the affected eye, and the glaucoma stage. Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 2. Answer: bilateral, stage Feedback: I.C.7.a.2 When a patient has bilateral glaucoma and both eyes are documented as being the same type and stage, and there is a code for bilateral glaucoma, report only the code for the type of glaucoma, bilateral, with the seventh character for the stage. Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes

Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 3. Answer: both, type, one Feedback: I.C.7.a.2 When a patient has bilateral glaucoma and both eyes are documented as being the same type and stage, and the classification does not provide a code for bilateral glaucoma (i.e. subcategories H40.11, H40.11 and H40.20) report only one code for the type of glaucoma with the appropriate seventh character for the stage. Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 4. Answer: different, laterality, each Feedback: I.C.7.a.3 When a patient has bilateral glaucoma and each eye is documented as having a different type or stage, and the classification distinguishes laterality, assign the appropriate code for each eye rather than the code for bilateral glaucoma. Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05

Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 5. Answer: admitted, progresses, highest Feedback: I.C.7.a.4 If a patient is admitted with glaucoma and the stage progresses during the admission, assign the code for highest stage documented. Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 6. Answer: seventh, ―4‖, clinical Feedback: I.C.7.a.5 Assignment of the seventh character ―4‖ for ―indeterminate stage‖ should be based on the clinical documentation. Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System

Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes Let’s Check It! Rules and Regulations 1. Answer: Within the palpebrae (eyelids), there are three types of glands: Moll‘s glands: ordinary sweat glands. Meibomian glands: sebaceous glands that secrete a tear film component that prevents tears from evaporating so that the area stays moist. Glands of Zeis: altered sebaceous glands that are connected to the eyelash follicles. Feedback: Within the palpebrae (eyelids), there are three types of glands: Moll‘s glands: ordinary sweat glands. Meibomian glands: sebaceous glands that secrete a tear film component that prevents tears from evaporating so that the area stays moist. Glands of Zeis: altered sebaceous glands that are connected to the eyelash follicles. Learning Objective: 11.01 Topic: Diseases of the External Optical System Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: The retina, the area of the eye that contains nerve endings, is responsible for receiving visual images and forwarding these images to the brain for analysis. The choroid is lightly attached to the retinal pigment epithelium (RPE) and is adjacent to the rods and cones that function as light receptors. The rods are located throughout the retina and are responsible for detecting movement so that you can see when something in front of you is moving. There are three types of cones that, together, provide designation for up to 150 shades of color: one type of cone reacts to red light, one to blue-violet light, and the third to green light. Isn‘t it amazing that you can go into a paint store and see 500 different colors, yet

the eye can really only interpret up to 150? The eye combines the light wavelengths to enable perception of a multitude of colors.

Feedback: The retina, the area of the eye that contains nerve endings, is responsible for receiving visual images and forwarding these images to the brain for analysis. The choroid is lightly attached to the retinal pigment epithelium (RPE) and is adjacent to the rods and cones that function as light receptors. The rods are located throughout the retina and are responsible for detecting movement so that you can see when something in front of you is moving. There are three types of cones that, together, provide designation for up to 150 shades of color: one type of cone reacts to red light, one to blue-violet light, and the third to green light. Isn‘t it amazing that you can go into a paint store and see 500 different colors, yet the eye can really only interpret up to 150? The eye combines the light wavelengths to enable perception of a multitude of colors.

Learning Objective: 11.02 Topic: Diseases of the Internal Optical System Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes

3. Answer: Patients with hypertension (high blood pressure) can develop damage to the retina because of the unusually high pressure of the blood traveling through the vessels. This condition is known as hypertensive retinopathy. The higher the pressure and the longer this condition has been ongoing, the more severely the retina may be harmed. Signs and symptoms most evident for those with hypertensive retinopathy include:  Double vision  Dimmed vision  Blindness (vision loss)  Headaches

Feedback: Patients with hypertension (high blood pressure) can develop damage to the retina because of the unusually high pressure of the blood traveling through the vessels. This condition is known as hypertensive retinopathy. The higher the pressure and the longer this condition has been ongoing, the more severely the retina may be harmed. Signs and symptoms most evident for those with hypertensive retinopathy include:  Double vision  Dimmed vision  Blindness (vision loss)  Headaches

Learning Objective: 11.03 Topic: Other Conditions Affecting the Eyes Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1

Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: Otosclerosis is a condition of increasing growth of spongy bone in the otic capsule. This growth interferes with the travel of sound vibrations from the tympanic membrane to the cochlea, causing a progressive deterioration of hearing. This condition is seen most frequently in adults between the ages of 18 and 35, and it is more prevalent in females. Report this condition with ICD11-CM code category H80.- Otosclerosis, with additional characters to identify the specific location within the ear as well as laterality. Feedback: Otosclerosis is a condition of increasing growth of spongy bone in the otic capsule. This growth interferes with the travel of sound vibrations from the tympanic membrane to the cochlea, causing a progressive deterioration of hearing. This condition is seen most frequently in adults between the ages of 18 and 35, and it is more prevalent in females. Report this condition with ICD-11-CM code category H80.- Otosclerosis, with additional characters to identify the specific location within the ear as well as laterality.

Learning Objective: 11.04 Topic: Dysfunctions of the Auditory System Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: While each individual will notice loss of hearing in a different way, these are the most common complaints: • Hearing speech and other sounds as muffled. • Having difficulty understanding conversations, particularly when in a crowd or in a noisy place (e.g., a restaurant). • Frequently asking others to speak more slowly, clearly, and loudly. • Turning up the volume of the television or radio. • No longer engaging in conversation. • Avoiding some social settings. Feedback: While each individual will notice loss of hearing in a different way, these are the most common complaints: • Hearing speech and other sounds as muffled. • Having difficulty understanding conversations, particularly when in a crowd or in a noisy place (e.g., a restaurant). • Frequently asking others to speak more slowly, clearly, and loudly. • Turning up the volume of the television or radio. • No longer engaging in conversation.

• Avoiding some social settings. Learning Objective: 11.05 Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes Let’s Check It! Basics 1. Answer: Stenosis, H04.573 Feedback: Stenosis of lacrimal sac, bilateral: Stenosis, H04.573 H04.573: Index>stenosis>lacrimal>sac>bilateral Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: Deafness, H93.013 Feedback: Transient ischemic deafness, bilateral: Deafness, H93.013 H93.013: Index>deafness> transient ischemic Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System

Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: Telangiectasis, H35.073 Feedback: Retinal telangiectasis, bilateral: Telangiectasis, H35.073 H35.073: Index>telangiectasis>retinal>bilateral Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4. Answer: Blepharitis, H01.011 Feedback: Ulcerative blepharitis, right upper: Blepharitis, H01.011 H01.011: Index>Blepharitis>ulcerative>right>upper Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 5. Answer: Cholesteatoma, H71.02 Feedback: Cholesteatoma of left attic: Cholesteatoma, H71.02 H71.12: Index>cholesteatoma>attic>left Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 6. Answer: Subluxation, H27.112 Feedback: Subluxation of lens, left eye: Subluxation, H27.112 H27.112: Index>subluxation sends you to dislocation>lens>partial>left Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 7. Answer: Granuloma, H05.111 Feedback: Granuloma of right orbit: Granuloma, H05.111 H05.111: Index>granuloma>orbit>right Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 8. Answer: Perichondritis, H61.022 Feedback: Chronic perichondritis of external ear, left: Perichondritis, H61.022 H61.022: Index>perichondritis>ear>chronic Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy

Est Time: 1-3 minutes 9. Answer: Dysfunction, H83.2X1 Feedback: Labyrinthine dysfunction, right: Dysfunction, H83.2X1 H83.2X1: Index>dysfunction>labyrinthine>right Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 10. Answer: Keratopathy, H18.12 Feedback: Bullous keratopathy, left: Keratopathy, H18.12 H18.12: Index>keratopathy>bullous>left Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes

11. Answer: Entropion, H02.022 Feedback: Mechanical entropion of eyelid, right lower: Entropion, H02.022 H02.022: Index>entropion>mechanical>right>lower Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 12. Answer: Perforation, H72.821 Feedback: Total attic perforation of right tympanic membrane: Perforation, H72.821 H72.821: Index>perforation>tympanum>total>right Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 13. Answer: mastoiditis, H70.13

Feedback: Recurrent bilateral mastoiditis: mastoiditis, H70.13 H70.13: Index>mastoiditis>chronic>bilateral Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 14. Answer: Ectropion, H02.135 Feedback: Senile ectropion of eyelid, left lower: Ectropion, H02.135 H02.135: Index>ectropion>senile>left>lower Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 15. Answer: Neuronitis, H81.22 Feedback: Vestibular neuronitis, left: Neuronitis, H81.22 H81.22: Index>neuronitis>vestibular>left Learning Objective: 11.01

Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes You Code It! Practice 1. Answer: H02.002 Feedback: H02.002: Index>Entropion>right>lower Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: H02.34 Feedback: H02.34: Index>Blepharochalasis>left>upper Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04

Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: Q12.0 Feedback: Q12.0: Index>Cataract>congenital Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: S06.6X0A, External Cause Codes provides for the instructor: W21.03XA, Y92.320, Y93.64, Y99.8 Feedback: S06.6X0A: Index>Injury>intracranial>subarachnoid hemorrhage, traumatic Provide for the Instructor W21.03XA: External cause index>struck>ball>baseball Y92.320: External cause index>place of occurrence>baseball field Y93.64: External cause index>activity>baseball Y99.8: External cause index>status>leisure activity Learning Objective: 11.01

Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: H18.611 Feedback: H18.611: Index>Keratoconus>stable>right Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: H53.2 Provided for the instructor: W06.XXXA, W22.09XA, Y92.013 Feedback: H53.2: Index>Diplopia Provided for the instructor: W06.XXXA: External Cause index>fall>from, off, of>bed>initial encounter W22.09XA: External cause index>striking against>object>stationary>initial encounter

Y92.013: External cause index>place of occurrence>residence>house, single family>bedroom Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: H20.023 Feedback: H20.023: Index>Iridocyclitis>acute>recurrent>bilateral Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: C30.1 Feedback: C30.1: Neoplasm table>ear>inner>malignant primary Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03

Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: H60.02 Feedback: H60.02: Index>Furuncle>ear sends you to abscess>ear>external Index>Abscess>ear>external>left Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: B36.9, H62.40 Feedback: B36.9: Index>Otomycosis H62.40: Index>Otitis>externa>in>mycosis NEC Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04

Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: H66.004 Feedback: Index>H66.004: Otitis>media>suppurative>acute>recurrent>right Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: H73.011 Feedback: H73.011: Index>Myringitis>acute>bullous>right Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System

Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: H81.03 Feedback: H81.03: Index>Meniere‘s disease>bilateral Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: H80.21 Feedback: H80.21: Index>Otosclerosis>cochlear>right Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: H93.221 H93.221: Index>Diplacusis>right Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application Application 1:

OLDENBERG, KYLE

Answer: H40.1412 Feedback: H40.1412: Index>Glaucoma>open angle>primary>capsular>right>moderate stage Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2:

TRUDELL, LEONARD

Answer: H59.43 Feedback: H59.43: Index>Endophthalmitis>bleb tells us to see Bleb H59.43: Index>Bleb>endophthalmitis Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3:

SIMONSON-WALKER, SIERRA

Answer: C44.229 Feedback: C44.229: Neoplasm table>ear>skin>squamous cell carcinoma>left Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4:

RIVERA, WALTER

Answer: E11.9, H60.21 Feedback: E11.9: Index>Diabetes>type 2 H60.21: Index>Otitis>externa>malignant>right Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5:

BARDARO, LYNNE

Answer: H61.121 Feedback: H61.121: Index>Hematoma>auricle tells us to see disorder, pinna>hematoma H61.121: Index>Disorder>pinna>hematoma>right Learning Objective: 11.01 Learning Objective: 11.02 Learning Objective: 11.03 Learning Objective: 11.04 Learning Objective: 11.05 Topic: Diseases of the External Optical System Topic: Diseases of the Internal Optical System Topic: Other Conditions Affecting the Eyes Topic: Dysfunctions of the Auditory System Topic: Causes, Signs, and Symptoms of Hearing Loss Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

Chapter 12 Coding Circulatory System Dysfunction 2024 Compliant Learning Outcomes LO 12.1 Abstract the documentation accurately to report heart dysfunction. LO 12.2 Discern the specifics of cardiovascular disease. LO 12.3 Evaluate documentation to determine details about abnormal blood pressure diagnoses. LO 13.4 Identify known manifestations of hypertension. LO 12.5 Interpret the details of cerebrovascular disease. LO 12.6 Distinguish the sequelae of cerebrovascular disease and report them accurately. Chapter Outline Learning Outcomes Key Terms Heart Conditions Heart Disorders Cardiac Arrest Dysrhythmia/Arrhythmia Mitral Valve Prolapse Atrial Fibrillation Heart Failure Types of Heart Failure Myocardial Infarction Anatomical Site of the AMI Subsequent MI Cardiovascular Conditions Deep Vein Thrombosis Atherosclerosis and Coronary Artery Disease (CAD) Hypertension Blood Pressure Elevated Blood Pressure Primary Hypertension Essential Hypertension

Secondary Hypertension Hypertensive Crisis Hypertension and Pregnancy Manifestations of Hypertension Hypertension with Heart Disease Hypertensive Heart Disease with Heart Failure Hypertensive Chronic Kidney Disease Hypertensive Heart and Chronic Kidney Disease Hypertensive Retinopathy Hypertensive Cerebrovascular Disease Other Circulatory Conditions CVA and Cerebral Infarction Heart Failure Myocardial Infarction Deep Vein Thrombosis CVA and Cerebral Infarction NIH Stroke Scale Sequelae of Cerebrovascular Disease Chapter Summary Chapter 12 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application Chapter Overview Circulatory conditions are very serious because they affect the flow of blood throughout the body. Blood circulates through arteries, veins, and capillaries to carry oxygen to the organs. While problems with circulation can affect a patient of any age, older individuals are more susceptible to these conditions. As the body ages, the strength and elasticity of blood vessels decrease, and they become less efficient. In addition, long-term, less-than-proper nutrition and lack of proper exercise take their toll and contribute to the circulatory system’s inability to do its job. Discussion Activities 1.

Hypotension/Hypertension/Elevated BP

Learning Objective: 12.3

What is the difference between hypotension, elevated blood pressure, and hypertension? Is one more dangerous than any of the others? Why?

Distinguishing between these three categories of diagnoses can be difficult for a new coder. Discuss the signs and symptoms of elevated blood pressure, hypotension, and hypertension. Review the guidelines (Section 1, subsection c. chapter 9, part a. Hypertension , subparagraphs 1 through 9.

2.

Cerebrovascular Accident (CVA)

Learning Objective: 12.5 and 12.6 CVA, also known as a stroke, can cause multiple problems. Discuss and explain the guidelines for reporting a CVA and/or CVA late effects. Refer to Official guidelines Section 1, subsection c. Chapter 9, part C. Intraoperative and postprocedural cerebrovascular accident.

DISCUSS THE COMPONENT SIGNS AND SYMPTOMS OF A CARDIOVASCULAR ACCIDENT (CVA) AS WELL AS THE MOST COMMON LATE EFFECTS ASSOCIATED WITH AN ATTACK. REVIEW MORE CLINICAL INFORMATION ABOUT A CVA TO SUPPORT ADDITIONAL DISCUSSION AND LEARNING:

CEREBROVASCULAR ACCIDENT PATHOPHYSIOLOGY - HEALTHCENTRAL Everything you need to know about strokes, including the most common causes, symptoms and treatments. http://www.healthcentral.com/heart-disease/h/cerebrovascular-accident-pathophysiology.html

3.

Myocardial Infarction (MI)

Learning Objective: 12.1 Also known as a heart attack, an MI can be quite devastating to a patient. Discuss and explain the process of reporting this condition and its variations. Refer to the Official Guidelines, Section 1, subsection c. chapter 9, part E. Acute myocardial infarction (AMI)

Find interactive activities as well as additional discussion points about MI, signs and symptoms, diagnostic tests, and treatments. Medline Plus (A service of the U.S. National Library of Medicine and the National Institutes of Health, “Heart Attack”): http://www.nlm.nih.gov/medlineplus/heartattack.html

Additional Resources Coronary Artery Disease Symptoms (Cleveland Clinic): http://my.clevelandclinic.org/heart/disorders/cad/cadsymptoms.aspx Heart Disease (Mayo Clinic): http://www.mayoclinic.com/health/heart-disease/DS01220/DSECTION=symptoms Heart Disease Symptoms (Yale Medical School): www.med.yale.edu/library/heartbk/9.pdf Heart Disease: Symptoms & Types (WebMD): http://www.webmd.com/heart-disease/guide/heart-disease-symptoms-types Heart Diseases/Cardiac Diseases (MedlinePlus): http://www.nlm.nih.gov/medlineplus/heartdiseases.html Grey’s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman’s Medical Dictionary: http://www.stedmans.com/ AAPC: http://www.aapc.com American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org American Medical Association: http://www.ama-assn.org

ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 12 Review Answer Key Let’s Check It! Terminology Part I Answer: 1. A Angina Pectoris 2. G Elevated Blood Pressure 3. E Cerebrovascular Accident (CVA) 4. D Cerebral Infarction 5. B Atherosclerosis 6. H Embolus 7. C Atrium 8. F Edema Learning Objective: 12.01 Learning Objective: 12.02 Learning Objective: 12.03 Learning Objective: 12.05 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: CVA and Cerebral Infarction Blooms: Remember

CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part II Answer: 1. K Ventricle 2. B Hypertension 3. A Gestational Hypertension 4. F NSTEMI 5. H STEMI 6. I Thrombus 7. E Myocardial Infarction (MI) 8. G Secondary Hypertension 9. D Infarction 10. J Vascular 11. C Hypotension Learning Objective: 12.01 Learning Objective: 12.03 Learning Objective: 12.05 Topic: Heart Conditions Topic: Hypertension Topic: CVA and Cerebral Infarction Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: A Arteries Feedback: Arteries = blood vessels that carry oxygenated blood from the heart to the tissues and cells throughout the body.

Learning Objective: 12.02 Topic: Cardiovascular Conditions Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2

ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: B I63.322 Feedback: The correct code for a diagnosis of a cerebral infarction due to thrombosis of left anterior cerebral artery is I63.322 I63.322: ICD-10-CM index>infarct>cerebral>thrombosis>cerebral artery>left Learning Objective: 12.05 Topic: CVA and Cerebral Infarction Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: C Dysrhythmia Feedback: Dysrhythmia, or arrhythmia, refers to an irregular heartbeat. Learning Objective: 12.01 Topic: Heart Conditions Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 4. Answer: D use both the appropriate fourth character, as shown in the Tabular List under category I11, and an additional code to specify the type of heart failure from category I50. Feedback: In those cases, where the physician states that the patient has heart failure due to hypertension, you will need to: 1. Use the appropriate fourth character, as shown in the tabular list under category I11. 2. Use an additional code to specify the type of heart failure from category I50. Learning Objective: 12.04 Topic: Manifestations of Hypertension Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: D ST elevation myocardial infarction Feedback: ST elevation myocardial infarction (STEMI) is a heart event during which the coronary artery is completely blocked by a thrombus or embolus. Learning Objective: 12.01 Topic: Heart Conditions Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 6. Answer: C the underlying condition code and the hypertension code. Feedback: Hypertension is coded as secondary when the physician uses terms such as ―due to‖ an underlying disease, ―resulting from‖ another condition, or other descriptors that point to another disease or condition. In such cases, you will need two codes: 1. The underlying condition 2. The type of secondary hypertension (I15.x) Learning Objective: 12.03 Topic: Hypertension Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: A if it is gestational hypertension Feedback: Gestational hypertension - Hypertension that develops during pregnancy and typically goes away once the pregnancy has ended. Learning Objective: 12.03 Topic: Hypertension Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: C the Z86.7- code subcategory Feedback: When a patient with no neurologic deficits and who had a previous diagnosis of cerebrovascular disease (which has since resolved) you should report from subcategory Z86.7- Personal history of disease of the circulatory system. Learning Objective: 12.06 Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: C R03.0 Feedback: According to the ICD-10-CM official guidelines I.C.9.a.7 Assign code R03.0, Elevated blood pressure reading without diagnosis of hypertension, unless patient has an establish diagnosis of hypertension. Learning Objective: 12.03 Topic: Hypertension Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: D ACE Feedback: A physician can support a diagnosis of hypertension with all of the following data trending, auscultation, ophthalmoscopy, patient history, chest X-ray, echocardiography, ECG or EKG. ACE is a medication= angiotensin converting enzyme inhibitors Learning Objective: 12.03 Topic: Hypertension Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Guidelines 1. Answer: N18, secondary Feedback: I.C.9.a.2 The appropriate code from category N18 should be used as a secondary code with a code from category I12 to identify the stage of chronic kidney disease. Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: I13, combination Feedback: I.C.9.a.3 The codes in category I13, Hypertensive heart and chronic kidney disease, are combination codes that include hypertension, heart disease and chronic kidney disease. Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension

Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: first, I60-I69, hypertension Feedback: I.C.9.a.4 For hypertensive cerebrovascular disease, first assign the appropriate code from categories I60-I69, followed by the appropriate hypertension code. Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: Two, underlying, I15 Feedback: I.C.9.a.6 Secondary hypertension is due to an underlying condition. Two codes are required: one to identify the underlying etiology and one from category I15 to identify the hypertension. Sequencing of codes is determined by the reason for admission/encounter. Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04

Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: Uncontrolled Feedback: I.C.9.a.9 Uncontrolled hypertension may refer to untreated hypertension or hypertension not responding to current therapeutic regimen. Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: admitted, before Feedback: I.C.9.b If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI), the AMI should be sequenced before the coronary artery disease.

Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: I69, current, deficits Feedback: I.C.9.d.2 Codes from category I69 may be assigned on a health care record with codes from I60-I67, if the patient has a current cerebrovascular disease and deficits from an old cerebrovascular disease. Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8.

Answer: site Feedback: I.C.9.e.1 The ICD-10-CM codes for acute myocardial infarction (AMI) identify the site, such as anterolateral wall or true posterior wall. Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: evolves, STEMI Feedback: I.C.9.e.1 If a type 1 NSTEMI evolves to STEMI, assign the STEMI code. Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes

10. Answer: AMI, subendocardial Feedback: I.C.9.e.3 If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded as a subendocardial AMI. Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: Systolic pressure (SP) is the measure of the maximum push of blood being forced into an artery from the ventricle during a cardiac contraction. This is the top number of a reported blood pressure. Diastolic pressure (DP) is the measure of the pressure of blood left in the arteries in between ventricular contractions. This is the bottom number of a reported blood pressure. Feedback: Systolic pressure (SP) is the measure of the maximum push of blood being forced into an artery from the ventricle during a cardiac contraction. This is the top number of a reported blood pressure. Diastolic pressure (DP) is the measure of the pressure of blood left in the arteries in between ventricular contractions. This is the bottom number of a reported blood pressure. Learning Objective: 12.03 Topic: Hypertension Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2

ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: High blood pressure, usually a chronic condition; often identified by a systolic blood pressure above 140 mm/Hg and/or a diastolic blood pressure above 90 mm/Hg. Elevated blood pressure is an occurrence of high blood pressure; an isolated or infrequent reading of a systolic blood pressure above 140 mm/Hg and/or a diastolic blood pressure above 90 mm/Hg. Feedback: High blood pressure, usually a chronic condition; often identified by a systolic blood pressure above 140 mm/Hg and/or a diastolic blood pressure above 90 mm/Hg. Elevated blood pressure is an occurrence of high blood pressure; an isolated or infrequent reading of a systolic blood pressure above 140 mm/Hg and/or a diastolic blood pressure above 90 mm/Hg. Learning Objective: 12.03 Topic: Hypertension Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: Gestational hypertension is hypertension that develops during pregnancy and typically goes away once the pregnancy has ended. Feedback: Gestational hypertension is hypertension that develops during pregnancy and typically goes away once the pregnancy has ended. Learning Objective: 12.03 Topic: Hypertension Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4.

Answer: STEMI (ST elevation myocardial infarction) is a heart event during which the coronary artery is completely blocked by a thrombus or embolis. ST segment is a specific range seen in an ECG (EKG). An NSTEMI (non - transmural myocardial infarction) indicates that only a portion of the artery is occluded (blocked). Feedback: STEMI (ST elevation myocardial infarction) is a heart event during which the coronary artery is completely blocked by a thrombus or embolis. ST segment is a specific range seen in an ECG (EKG). An NSTEMI (non - transmural myocardial infarction) indicates that only a portion of the artery is occluded (blocked). Learning Objective: 12.01 Topic: Heart Conditions Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: Hypertension with Heart Disease Heart conditions classified to I50.- or I51.4-I51.9, are assigned to, a code from category I11, Hypertensive heart disease, when a causal relationship is stated (due to hypertension) or implied (hypertensive). Use an additional code from category I50, Heart failure, to identify the type of heart failure in those patients with heart failure. The same heart conditions (I50.-, I51.4-I51.9) with hypertension, but without a stated causal relationship, are coded separately. Sequence according to the circumstances of the admission/encounter. Feedback: Hypertension with Heart Disease Heart conditions classified to I50.- or I51.4-I51.9, are assigned to, a code from category I11, Hypertensive heart disease, when a causal relationship is stated (due to hypertension) or implied (hypertensive). Use an additional code from category I50, Heart failure, to identify the type of heart failure in those patients with heart failure. The same heart conditions (I50.-, I51.4-I51.9) with hypertension, but without a stated causal relationship, are coded separately. Sequence according to the circumstances of the admission/encounter. Learning Objective: 12.04 Topic: Manifestations of Hypertension Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes You Code It! Basics 1. Answer: Failure, I50.31 Feedback: Acute diastolic (congestive) heart failure: Failure, I50.31 I50.31: Index>failure>heart>diastolic>acute Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: Hypertension, I15.2 Feedback: Secondary hypertension due to pheochromocytoma: Hypertension, I15.2 I15.2: Index>hypertension>secondary>due to> pheochromocytoma Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: Block, I44.5 Feedback: Left posterior fascicular block: Block, I44.5 I44.5: Index>block>fascicular>posterior>left Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: Aneurysm, I25.3 Feedback: Aneurysm of heart, 6 weeks‘ duration: Aneurysm, I25.3 I25.3: Index>aneurysm>heart>6 weeks Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction

Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: Cardiomyopathy, I25.5 Feedback: Ischemic cardiomyopathy: Cardiomyopathy, I25.5 I25.5: Index>cardiomyopathy>ischemic Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: Occlusion, I25.82 Feedback: Chronic total occlusion of coronary artery: Occlusion, I25.82 I25.82: Index>occlusion>artery>coronary>chronic total Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension

Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: Atherosclerosis, I25.812 Feedback: Atherosclerosis of bypass graft of coronary artery of transplanted heart: Atherosclerosis, I25.812 I25.812: Index>atherosclerosis>transplanted heart>bypass graft Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: Embolism, I82.211 Feedback: Chronic embolism of superior vena cava: Embolism, I82.211 I82.211: Index>embolism>vena cava>superior>chronic Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions

Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: Rupture, I28.8 Feedback: Rupture of pulmonary vessels: Rupture, I28.8 I28.8: Index>rupture>pulmonary vessel Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: Stenosis, I37.0 Feedback: Nonrheumatic pulmonary valve stenosis: Stenosis, I37.0 I37.0: Index>stenosis>pulmonary>valve Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions

Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 12. Answer: Endocarditis, I38 Feedback: Arteriosclerotic endocarditis: Endocarditis, I38 I38: Index>endocarditis>arteriosclerotic Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 12. Answer: Myocarditis, I40.1 Feedback: Giant cell myocarditis: Myocarditis, I40.1 I40.1: Index>myocarditis>giant cell Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06

Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 13. Answer: Arrest, I46.2 Feedback: Cardiac arrest due to cardiac condition: Arrest, I46.2 I46.2: Index>arrest>cardiac>due to>cardiac condition Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 14. Answer: Fibrillation, I49.01 Feedback: Ventricular fibrillation: Fibrillation, I49.01 I49.01: Index>fibrillation>ventricular Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05

Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 15. Answer: Hypotension, G90.3 Feedback: Neurogenic orthostatic hypotension: Hypotension, G90.3 G90.3: Index>hypotension>orthostatic>neurogenic Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes You Code It! Practice: 1. Answer: I20.0, F17.210 Feedback: I20.0: Index>Angina>unstable F17.210: Index>Dependence>drug>nicotine>cigarettes

Learning Objective: 12.01

Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: I09.0 Feedback: I09.0: Index>Myocarditis>rheumatic Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: I13.10, N18.2 Feedback: I13.10: Index>Hypertension>cardiorenal>without heart failure>with stages 14 chronic kidney disease

N18.2: Disease>kidney>chronic>stage 2 (mild) Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: I08.0 Feedback: I08.0: Index>Insufficiency>aortic>rheumatic>with>mitral>valve disease Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: I48.0

Feedback: I48.0: Index>Fibrillation>atrial>paroxysmal Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 6. Answer: I69.320 Feedback: I69.320: Index>Aphasia>following>cerebrovascular disease>cerebral infarction Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 7. Answer: I97.0

Feedback: I97.0: Index>postcardiotomy syndrome Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 8. Answer: I21.19 Feedback: I21.19: Index>Infarction>myocardium>ST elevated>inferior wall Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 9. Answer: I82.B22 Feedback: I82.B22: Index>embolism>vein>subclavian>chronic>left

Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 10. Answer: I25.6 Feedback: I25.6: Index>Ischemia>myocardium>silent Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 12. Answer: I70.243, I70.92, L97.321 Feedback: I70.243: Index>Arteriosclerosis>extremities>leg>left>with>ulceration>ankle

I70.92: Index>Occlusion>artery>total>extremities L97.321: Index>Ulcer>lower limb>ankle>left>with>skin breakdown only Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 12. Answer: I26.02 Feedback: I26.02: Index>Embolism>pulmonary>saddle>with acute cor pulmonale Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 13.

Answer: I30.1, B97.30 Feedback: I30.1: Index>Pericarditis>infective B97.30: Index>Infection>retrovirus>as cause of disease classified elsewhere Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 14. Answer: I73.00 Feedback: I73.00: Index>Raynaud‘s syndrome Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

15. Answer: J85.2, I76, I74.11, B95.61 Feedback: J85.2: Index>Abscess>lung I76: Index>Embolism>artery>septic I74.11: Index>Embolism>aorta>thoracic B95.61: Index>Infection>staphylococcal>as cause of disease classified elsewhere>aureus Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Application: Application 1:

PETERS, CHARLENE

Answer: I69.322 Feedback: I69.322: Index>Dysarthria>following>cerebral infarction Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2:

CROWDER, CHRISTOPHER

Answer: I82.432, N39.0, G20.A1 Feedback: I82.432: Index>Thrombosis>vein>deep (DVT)>popliteal>left N39.0: Index>Infection>urinary (tract) G20.A1: Index>Disease>Parkinson‘s Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3:

NOLAN, SHERYESSE

Answer: I12.9, N18.4, I50.1, I50.21 Feedback: I12.9: Index>Hypertension>kidney>with>stage 4 CKD N18.4: Index>Disease>kidney>stage 4 I50.1: Index>Failure>ventricular>left I50.21: Index>Failure>heart>systolic>acute Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04

Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4:

GUZMANN, EVAN

Answer: I65.1, I65.22, I65.02 Feedback: I65.1: Index>Occlusion>artery>basilar I65.22: Index>Occlusion>artery>carotid>left I65.02: Index>Occlusion>artery>vertebral>left Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5:

WEINER, PHILLIP

Answer: I21.09, I11.0, I50.22, I49.9

Feedback: I21.09: Index>Infarct>myocardial>STEMI>anterior I11.0: Index>Hypertension>with>heart failure I50.22: Index>Failure>heart>systolic>chronic I49.9: Index>Arrhythmia Learning Objective: 12.01 Learning Objective: 12.02 Learning objective: 12.03 Learning Objective: 12.04 Learning Objective: 12.05 Learning Objective: 12.06 Topic: Heart Conditions Topic: Cardiovascular Conditions Topic: Hypertension Topic: Manifestations of Hypertension Topic: CVA and Cerebral Infarction Topic: Sequelae of Cerebrovascular Disease Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 13 Coding Respiratory Conditions 2024 Compliant Learning Outcomes

LO 13.1 Discern the various underlying causes of respiratory disorders. LO 13.2 Report the different types of respiratory disorders. LO 13.3 Determine the correct way to report cases of pneumonia and influenza. LO 13.4 Analyze the details required to report chronic respiratory conditions. LO 13.5 Accurately code any involvement of tobacco in the patient’s respiratory disorder. LO 13.6 Identify the appropriate use of external cause codes when applicable to respiratory conditions.

Chapter Outline Learning Outcomes Key Terms Underlying Causes of Respiratory Disorders

Congenital Anomalies Genetic Disorders Manifestations of Another Disease Trauma Environment Lung Infections Lifestyle Behaviors Disorders of the Respiratory System Pleural Disorders Pulmonary Embolism Respiratory Syncytial Virus Infections Pulmonary Fibrosis Respiratory Failure Pneumonia and Influenza Pneumonia Pneumonia as a Manifestation of HIV Ventilator-Associated Pneumonia Influenza Chronic Respiratory Disorders Chronic Obstructive Pulmonary Disease Exacerbation and Status Asthmaticus Reporting Tobacco Involvement Respiratory Conditions Requiring External Cause Codes External Cause Codes Chapter Summary Chapter 13 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application Chapter Overview As your students know, breathing is an important, crucial part of life. The human body accomplishes this function via the respiratory system, which is designed to process oxygen (O2) and carbon dioxide (CO2). The respiratory system

includes many anatomical sites beginning with the nose and continuing down the windpipe to the lungs and the bronchi. The central nervous system controls respiration from the lateral medulla oblongata of the brain stem. Specifically, the parts of the respiratory system include: The upper respiratory system 

Nose, nasal cavity, and nasal conchae



Frontal and sphenoidal sinuses



Internal nares



Nasopharynx



Hyoid bone



Pharynx

The lower respiratory system 

Larynx (voice box)



Trachea (windpipe)



Bronchus



Lungs (right and left)



Bronchioles



Diaphragm

Respiration is the term used for what is commonly known as breathing and is made up of two parts: inspiration—bringing oxygen into the body; and expiration—getting rid of carbon dioxide. Discussion Activities 1.

Discuss the various conditions that can affect the different parts of the respiratory system. [Learning Outcome: 13.2]

Students should review each individual segment of the upper and lower respiratory systems and the health-related problems that can affect them. Discuss signs and symptoms, as well as the specific names of the diseases.

2.

Identify the relationship between the codes for respiratory conditions and other codes to indicate aspects such as an external cause. Provide examples and discuss how to code those scenarios. [Learning Outcome: 13.6]

This discussion can reinforce the connection between bacteria and viruses, the impact of environmental conditions that may cause a problem, as well as other underlying conditions that can affect the respiratory system’s health.

Additional Resources Asthma in Children (Merck Manuals): http://www.merckmanuals.com/home/sec23/ch274/ch274b.html Chronic Respiratory Diseases (World Health Organization): http://www.who.int/respiratory/en/

COPD (Chronic Obstructive Pulmonary Disease) (MedlinePlus): http://www.nlm.nih.gov/medlineplus/copdchronicobstructivepulmonarydisease.html Lung Diseases (Medline Plus): http://www.nlm.nih.gov/medlineplus/lungdiseases.html Respiratory Diseases (DHHS): http://www.healthfinder.gov/Scripts/SearchContext.asp?topic=744

Grey’s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman’s Medical Dictionary: http://www.stedmans.com/ AAPC: http://www.aapc.com American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org American Medical Association: http://www.ama-assn.org

ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Similar to smoking is a lifestyle behavior known as vaping. Using an electronic cigarette to simulate tobacco smoking began as a healthier alternative. However, individuals using this method have developed specific respiratory conditions. When the documentation identifies vaping-related disorder, report code U07.0 as the principal diagnosis code. Report manifestations separately, using the appropriate codes, such as acute respiratory failure with a code from J96.0- .

Chapter 13 Review Answer Key Let’s Check It! Terminology Answer: 1. B Exacerbation 2. C Influenza 3. A Chronic Obstructive Pulmonary Disease (COPD) 4. F Respiratory Disorder 5. D Pneumonia 6. G Status Asthmaticus 7. E Pneumothorax Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts:

1. Answer: D chronic obstructive pulmonary disease Feedback: COPD stands for chronic obstructive pulmonary disease. Learning Objective: 13.04 Topic: Chronic Respiratory Disorders Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: C emphysema Feedback: The 3 clinical types of COPD are chronic bronchitis, emphysema and asthma. Learning Objective: 13.04 Topic: Chronic Respiratory Disorders Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: D underlying disease first, pneumonia second Feedback: In some cases, pneumonia may be a manifestation of HIV infection. Therefore, if the notes report that the patient has also been diagnosed with HIV-positive status, you have to include: B20 Human immunodeficiency virus (HIV) disease Code B20 should be listed first, followed by the appropriate pneumonia code. There are other types of pneumonia that may have other underlying diseases. Learning Objective: 13.03 Topic: Pneumonia and Influenza Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4.

Answer: D all of these Feedback: Respiratory disorders can be caused by many things, including trauma, genetics, environmental concerns, congenital anomalies, and infection. Learning Objective: 13.01 Topic: Underlying Causes of Respiratory Disease Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: B code both the known organism and the respiratory condition Feedback: Some pneumonia codes are combination codes reporting both the condition (pneumonia) and the pathogen (adenovirus or Klebsiella). Not all pneumonia codes are combination codes, so you need to remember to use an additional code to identify the pathogen. Learning Objective: 13.03 Topic: Pneumonia and Influenza Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: A code only the status asthmaticus Feedback: Status asthmaticus is the condition of asthma that is lifethreatening and does not respond to therapeutic treatments. Status asthmaticus, being the more severe condition, will override an additional diagnosis of acute exacerbation of asthma; therefore acute exacerbation will not be coded. Learning Objective: 13.04 Topic: Chronic Respiratory Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7.

Answer: D I26.02 Feedback: I26.02: Index>embolism>pulmonary>saddle>with acute cor pulmonale Learning Objective: 13.02 Topic: Disorders of the Respiratory System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: D only if there is an external cause codes Feedback: There are respiratory conditions that may require external cause codes to explain how, and sometimes where, an external condition was involved in causing this health problem. Learning Objective: 13.06 Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: B Use Feedback: Use is the term that identifies that the patient smokes tobacco on a regular basis, taken by his or her own initiative, even though the substance is known to be a detriment to one‘s health. There are no obvious clinical manifestations.

Learning Objective: 13.05 Topic: Reporting Tobacco Involvement Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 10. Answer: C T52.0X1A, J69.1 Feedback:

T52.0X1A: Drug table>oil (of)>lubricating oil>poisoning accidental, unintentional>initial encounter J69.1: Index>Pneumonitis>due to>inhalation>oils, essences Instructions for sequencing is stated under code J69.1 Learning Objective: 13.03 Topic: Pneumonia and Influenza Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Guidelines: 1. Answer: exacerbation Feedback: I.C.10.a.1 An acute exacerbation is a worsening or a decompensation of a chronic condition. Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: J96.0, J96.2 Feedback: I.C.10.b.1 A code from subcategory J96.0, Acute respiratory failure, or subcategory J96.2, Acute and chronic respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly

responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: secondary, principal Feedback: I.C.10.b.2 Respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis. Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes

4. Answer: confirmed Feedback: I.C.10.c Code only confirmed cases of influenza due to certain identified influenza viruses (category J09), and due to other identified influenza virus (category J10). Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: all, documentation Feedback: I.C.10.d.1 As with all procedural or postprocedural complications, code assignment is based on the provider‘s documentation of the relationship between the condition and the procedure. Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: J95.851 Feedback: I.C.10.d.1 Code J95.851, Ventilator associated pneumonia, should be assigned only when the provider has documented ventilator associated pneumonia (VAP). Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: not, mechanical Feedback: I.C.10.d.1 Code J95.851 should not be assigned for cases where the patient has pneumonia and is on a mechanical ventilator and the provider has not specifically stated that the pneumonia is ventilator-associated pneumonia. Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders

Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: one, admission Feedback: I.C.10.d.2 A patient may be admitted with one type of pneumonia (e.g., code J13, Pneumonia due to Streptococcus pneumonia) and subsequently develop VAP. In this instance, the principal diagnosis would be the appropriate code from categories J12-J18 for the pneumonia diagnosed at the time of admission. Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: Pleural effusion is the presence of excess fluid in the pleural cavity, frequently a manifestation of congestive heart failure. J91.0: index>effusion>pleural>malignant Feedback: Pleural effusion is the presence of excess fluid in the pleural cavity, frequently a manifestation of congestive heart failure. J91.0: index>effusion>pleural>malignant

Learning Objective: 13.02 Topic: Disorders of the Respiratory System Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: When a patient needs help breathing because of a malfunction in the respiratory system, he or she may be placed on a ventilator, a machine that will essentially complete respiration. While the patient is hooked up to the machine, which uses a tube placed into the patient‘s throat, pathogens can travel directly into the patient‘s lungs, potentially resulting in the development of ventilator-associated pneumonia (VAP). The attending physician must specifically document the diagnosis of VAP before you can report code J95.851. Only the physician can link the ventilator with the infection. If the documentation is not clear, you must query the physician for clarification. Beneath this code is a Use additional code notation reminding you that you will need to report a second code to identify the specific organism responsible for this infection. Feedback: When a patient needs help breathing because of a malfunction in the respiratory system, he or she may be placed on a ventilator, a machine that will essentially complete respiration. While the patient is hooked up to the machine, which uses a tube placed into the patient‘s throat, pathogens can travel directly into the patient‘s lungs, potentially resulting in the development of ventilator-associated pneumonia (VAP). The attending physician must specifically document the diagnosis of VAP before you can report code J95.851. Only the physician can link the ventilator with the infection. If the documentation is not clear, you must query the physician for clarification. Beneath this code is a Use additional code notation reminding you that you will need to report a second code to identify the specific organism responsible for this infection. Learning Objective: 13.03 Topic: Pneumonia and Influenza Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3.

Answer: Exacerbation is an increase in the severity of a disease or its symptoms. Status asthmaticus is the condition of asthma that is life-threatening and does not respond to therapeutic treatments. Feedback: Exacerbation is an increase in the severity of a disease or its symptoms. Status asthmaticus is the condition of asthma that is life-threatening and does not respond to therapeutic treatments. Learning Objective: 13.04 Topic: Chronic Respiratory Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: Exposure means that the patient has been in contact with, or in close proximity to, a source of tobacco smoke in such a way that the harmful effects of this agent may impact the patient. Use is the term that identifies that the patient smokes tobacco on a regular basis, taken by his or her own initiative, even though the substance is known to be a detriment to one‘s health. There are no obvious clinical manifestations Abuse describes the patient‘s habitual smoking tobacco, taken by his or her own initiative even though the substance is known to be a detriment to one‘s health. Clinical manifestations are evident as signs and symptoms develop. Dependence indicates the patient‘s compulsive, continuous smoking of tobacco that has resulted in significant clinical manifestations as well as the physiological need for the substance to function normally. Any interruption results in signs and symptoms of withdrawal, occurring within a continuous 12 - month time frame. History is when a patient has successfully quit using tobacco products. Feedback: Exposure means that the patient has been in contact with, or in close proximity to, a source of tobacco smoke in such a way that the harmful effects of this agent may impact the patient. Use is the term that identifies that the patient smokes tobacco on a regular basis, taken by his or her own initiative, even though the substance is known to be a detriment to one‘s health. There are no obvious clinical manifestations

Abuse describes the patient‘s habitual smoking tobacco, taken by his or her own initiative even though the substance is known to be a detriment to one‘s health. Clinical manifestations are evident as signs and symptoms develop. Dependence indicates the patient‘s compulsive, continuous smoking of tobacco that has resulted in significant clinical manifestations as well as the physiological need for the substance to function normally. Any interruption results in signs and symptoms of withdrawal, occurring within a continuous 12 - month time frame. History is when a patient has successfully quit using tobacco products. Learning Objective: 13.05 Topic: Reporting Tobacco Involvement Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: There are respiratory conditions that may require external cause codes in order to explain how, and sometimes where, an external condition was involved in causing this health problem. Some of these conditions are: • Cicatrix of trachea might need an external cause code to identify it as a late effect of an injury or poisoning. • Extrinsic allergic alveolitis, farmers‘ lung might need an external cause code for a workers‘ compensation claim. • ―Ventilation‖ pneumonitis would need an external cause code to report ―sick building syndrome‖ for workers‘ compensation • Respiratory conditions due to chemical fumes and vapors would need an external cause code to identify the chemical. • Respiratory conditions due to other and unspecified external agents would need an external cause code to identify the external cause of the condition. • Iatrogenic pneumothorax would need an external cause code to identify that it was a postoperative condition. Feedback: There are respiratory conditions that may require external cause codes in order to explain how, and sometimes where, an external condition was involved in causing this health problem. Some of these conditions are: • Cicatrix of trachea might need an external cause code to identify it as a late effect of an injury or poisoning. • Extrinsic allergic alveolitis, farmers‘ lung might need an external cause code for a workers‘ compensation claim. • ―Ventilation‖ pneumonitis would need an external cause code to report ―sick building syndrome‖ for workers‘ compensation

• Respiratory conditions due to chemical fumes and vapors would need an external cause code to identify the chemical. • Respiratory conditions due to other and unspecified external agents would need an external cause code to identify the external cause of the condition. • Iatrogenic pneumothorax would need an external cause code to identify that it was a postoperative condition. Learning Objective: 13.06 Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes You Code It! Basics: 1. Answer: Rhinitis, J30.0 Feedback: Vasomotor rhinitis: Rhinitis, J30.0 J30.0: Index>rhinitis>vasomotor Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: Catarrh, J31.0 Feedback: Nasal catarrh, acute: Catarrh, J31.0 J31.0: Index>catarrh see rhinitis>chronic

Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: Empyema, J01.31 Feedback: Acute recurrent empyema of sphenoidal sinus: Empyema, J01.31 J01.31: Index>empyema>sphenoidal see sinusitis>acute>sphenoidal Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4. Answer: Hypertrophy, J35.1 Feedback: Hypertrophy of tonsils: Hypertrophy, J35.1

J35.1: Index>hypertrophy>tonsils Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 5. Answer: Laryngitis, J05.0 Feedback: Obstructive laryngitis: Laryngitis, J05.0 J05.0: Index>laryngitis>obstructive Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 6. Answer: Laryngotracheitis, J37.1

Feedback: Chronic laryngotracheitis: Laryngotracheitis, J37.1 J37.1: Index>laryngotracheitis>chronic Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 7. Answer: Pneumonia, J69.8 Feedback: Aspiration pneumonia due to solids and liquids: Pneumonia, J69.8 J69.8: Index>pneumonia>aspiration>due to>solids, liquids NEC Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 8.

Answer: Bronchitis, J20.6 Feedback: Bronchitis due to rhinovirus: Bronchitis, J20.6 J20.6: Index>bronchitis>virus>rhinovirus Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 9. Answer: Celluitis, J34.0 Feedback: Cellulitis of nose: Celluitis, J34.0 J34.0: Index>cellulitis>nose Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes

10. Answer: Degeneration, J33.1 Feedback: Polypoid sinus degeneration: Degeneration, J33.1 J33.1: Index>degeneration>sinus>polypoid Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 11. Answer: Vegetations, J35.8 Feedback: Adenoid vegetations: Vegetations, J35.8 J35.8: Index>vegetation>adenoid Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy

Est Time: 1-3 minutes 13. Answer: Abscess, J85.2 Feedback: Abscess of lung: Abscess, J85.2 J85.2: Index>abscess>lung Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 13. Answer: Bronchiectasis, J47.1 Feedback: Bronchiectasis with exacerbation: Bronchiectasis, J47.1 J47.1: Index>bronchiectasis>with>exacerbation Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 1 Easy Est Time: 1-3 minutes 14. Answer: Pleurisy, J86.0 Feedback: Seropurulent pleurisy with fistula: Pleurisy, J86.0 J86.0: Index>pleurisy>seropurulent>see pyothroax>with fistula Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 15. Answer: Gangrene, J85.0 Feedback: Pulmonary gangrene: Gangrene, J85.0 J85.0: Index>gangrene>pulmonary Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes You Code It! Practice: 1. Answer: J18.8, Z21 Feedback: J18.8: Index>Pneumonia>specified NEC Z21: Index>Human>immunodeficiency virus disease>asymptomatic status Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 2. Answer: J02.0 Feedback: J02.0: Index>Pharyngitis>streptococcal Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 3. Answer: J15.3 Feedback: J15.3: Index>Pneumonia>streptococcus>group B Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 4. Answer: J06.9, H10.33 Feedback: J06.9: Index>Infection>respiratory>upper H10.33: Index>Conjunctivitis>acute>bilateral Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 5. Answer: J35.03 Feedback: J35.03: Index>Tonsillitis>chronic>with>adenoiditis Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 6. Answer: J05.10, B96.3 Feedback: J05.10: Index>Epiglottitis>acute B96.3: Index>Infection>haemophilus>influenza>as cause of disease classified elsewhere Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders

Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 7. Answer: J09.X2, J91.8 Feedback: J09.X2: Index>Influenza>A J91.8: Index>Effusion>pleural>in other conditions classified elsewhere Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 8. Answer: J20.4 Feedback: J20.4: Index>Bronchitis>acute>due to>virus>parainfluenza Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza

Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 9. Answer: J44.1 Feedback: J44.1: Index>Disease>pulmonary>chronic obstructive>with> exacerbation Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 10. Answer: J38.2, Z72.0 Feedback: J38.2: Index>Nodules>vocal cord Z72.0: Index>Tobacco>use Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease

Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 11. Answer: J34.2, W21.05XA, Y92.310, Y93.67, Y99.8 Feedback: J34.2: Index>Deviation>septum (nasal) (acquired) W21.05XA: External causes index>struck accidentally by>ball>basketball>initial encounter Y92.310: External causes index>place of occurrence>sports area>athletic>court> Basketball Y93.67: External causes index>activity>basketball Y99.8: External causes index>status>leisure activity Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 12. Answer: J63.2 Feedback: J63.2: Index>Berylliosis Learning Objective: 13.01

Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 13. Answer: J38.02 Feedback: J38.02: Index>Paralysis>laryngeal nerve>bilateral Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 14. Answer: J82.82, J93.13 Feedback: J82.82: Index>Pneumonia>eosinophilic J93.13: Index>Pneumothorax>spontaneous>secondary

Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 15. Answer: J45.52 Feedback: J45.52: Index>Asthma>severe persistent>with>status asthmaticus Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes You Code It! Application: Application 1: YOUNG, ELIAS

Answer: J96.10, R00.0 Feedback: J96.10: Index>Failure>respiratory>chronic R00.0: Index>Tachycardia>sinus Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: NADER, ERICK Answer: J38.5 Feedback: J38.5: Index>Croup>stridulous Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: SMUTH, SARAH Answer: J95.89, J98.11 Feedback: J95.89: Index>Complication>post-procedural>specified NEC>respiratory system J98.11: Index>Atelectasis Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: ALBERTSON, JONAH Answer: J80, V43.52XA Feedback: J80: Index>Distress>respiratory>adult V43.52XA: External cause index>accident>car>driver>collision>car>initial encounter Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders

Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: MASHEN, CYRUS Answer: R09.1 Feedback: R09.1: Index>Pleurisy Learning Objective: 13.01 Learning Objective: 13.02 Learning Objective: 13.03 Learning Objective: 13.04 Learning Objective: 13.05 Learning Objective: 13.06 Topic: Underlying Causes of Respiratory Disease Topic: Disorders of the Respiratory System Topic: Pneumonia and Influenza Topic: Chronic Respiratory Disorders Topic: Reporting Tobacco Involvement Topic: Respiratory Conditions Requiring External Cause Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 14 Coding Digestive Conditions 2024 Compliant Learning Outcomes

LO 14.1 Analyze the documentation for applicable details needed to report diseases affecting the mouth and salivary glands accurately. LO 14.2 Interpret documentation to determine necessary details to report conditions affecting the esophagus and stomach correctly. LO 14.3 Apply your knowledge to identify main terms relating to intestinal disorders.

LO 14.4 Evaluate the specifics from the documentation related to digestive accessory organs and malabsorption disorders accurately. LO 14.5 Determine when additional codes are required to report the involvement of alcohol. Chapter Outline Learning Outcomes Key Terms Diseases of Oral Cavity and Salivary Glands Oral Cavity Salivary Glands Conditions of the Esophagus and Stomach Esophagus Gastroesophageal Reflux Disease (GRD) Stomach Ulcers Hernias Conditions Affecting the Intestines Small Intestine Gastrojejunal Ulcer Large Intestine Ulcerative Colitis Diverticular Disease of the Intestine Dysfunction of the Digestive Accessory Organs and Malabsorption Gallbladder Cholecystitis Pancreas Pancreatitis Liver Hepatitis Cirrhosis Celiac Disease Reporting the Involvement of Alcohol in Digestive Disorders Chapter Summary Chapter 14 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Rules and Regulations

You Code It! Basics You Code It! Practice You Code It! Application

Chapter Overview The complex mechanisms that permit our bodies to function require energy. This energy is extracted from nourishment and is a requirement for life. The old saying “You are what you eat” may not be specifically accurate, but without food and drink we cannot exist. The digestive system is referred to in two parts: the alimentary canal and the accessory organs. You experience the workings of your digestive system every day. Liquids and solids enter your body and provide nourishment to the cells, tissues, and organs so that they have the energy to function. The digestive system starts at the mouth and ends at the anus.

Discussion Activities 3.

Enumerate the various conditions, signs, and symptoms that support medical necessity for an endoscopic procedure. [Learning Outcome: 14.2]

Students should review not only therapeutic endoscopies to repair confirmed diagnoses such as GERD (gastroesophageal reflux disease) or a gastric ulcer, but also signs and symptoms for a diagnostic endoscopy, such as spitting up blood.

4.

Identify the relationship between alcohol abuse and alcohol dependence and its impact on the digestive system. Include at least one specific diagnosis and what codes would be reported. [Learning Outcome: 14.5]

This discussion can reinforce the connection between alcohol and deterioration of the digestive tract, as well as the rules in ICD-10-CM requiring the additional code to report the role the alcohol played.

Additional Resources Digestive Diseases A-Z (National Institute of Diabetes and Digestive and Kidney Diseases): http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/Pages/default.aspx Overview of Digestive Symptoms (Merck Manuals): http://www.merckmanuals.com/home/digestive_disorders/symptoms_of_digestive_disorders/overview_of_ digestive_symptoms.html Digestive Disorders Center (eMedicineHealth): http://www.emedicinehealth.com/digestivedisorders/center.htm

Grey’s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman’s Medical Dictionary: http://www.stedmans.com AAPC: http://www.aapc.com American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org American Medical Association: http://www.ama-assn.org

ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm

Chapter 14 Review Answer Key Let’s Check It! Terminology Part I Answer: 1. K Teeth 2. H Pancreatic Islets 3. G Pancreas 4. D Ileum 5. J Stomach 6. L Vermiform Appendix 7. I Rectum 8. C Esophagus 9. F Liver 10. A Anus 11. B Duodenum 12. E Jejunum 1. Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part II Answer: 1. B Cecum 2. D Descending Colon 3. H Transverse Colon 4. C Common Bile Duct 5. A Ascending Colon 6. G Sigmoid Colon 7. E Oral Cavity 8. F Salivary Glands

Learning Objective: 14.01 Learning Objective: 14.03 Learning Objective: 14.04 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part III Answer: 1. J Obstruction 2. K Perforation 3. A Accessory Organs 4. B Cholelithiasis 5. I Mesentery 6. L Sphincter 7. E Gallbladder 8. D Fundus 9. C Edentulism 10. H Hernia 11. F Gangrene 12. G Hemorrhage Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Let’s Check It! Concepts: 1. Answer: B K44.0 Feedback: K44.0: Index>Hernia>diaphragmatic>with>obstruction Learning Objective: 14.02 Topic: Conditions of the Esophagus and Stomach Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: C small intestine Feedback: The small intestine consists of the duodenum, jejunum and ileum. Learning Objective: 14.03 Topic: Conditions Affecting the Intestines Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: C III Feedback: Class I describes the stage of edentulism believed to have the best prognosis to have successful treatment using conventional prosthodontic techniques. Class II identifies a patient with deterioration of the gums and other supporting structures, along with systemic disease interactions, soft tissue concerns, as well as patient management and/or lifestyle considerations affecting the prognosis of the treatment. Class III establish the existence of other factors significantly affecting the outcomes of treatment and the need for surgical revision of the supporting structures (gums and bone) to create an opportunity for prosthodontics. Class IV reports a severely compromised condition of the supporting structures requiring surgical reconstruction. If due to the patient health, personal preferences, past dental history, along with financial considerations, a customized prosthodontic technique may need to be created for an acceptable outcome. Learning Objective: 14.01 Topic: Diseases of Oral Cavity and Salivary Glands

Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 4. Answer: D all of these Feedback: Cirrhosis of the live can be caused by abuse of alcohol, trauma or disease like hepatitis B or C. Learning Objective: 14.04 Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: A esophagus Feedback: Hiatal hernia (esophageal) may occur when a portion of the stomach pokes through an opening in the diaphragm. Learning Objective: 14.02 Topic: Conditions of the Esophagus and Stomach Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 6. Answer: B K35.200 Feedback: K35.200: Appendicitis>acute>with>peritonitis>generalized Learning Objective: 14.03 Topic: Conditions Affecting the Intestines Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 1-3 minutes 7. Answer: B hepatic flexure and the splenic flexure Feedback: Transverse colon is the portion of the large intestine that connects hepatic flexure to the splenic flexure. Learning Objective: 14.03 Topic: Conditions Affecting the Intestines Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 8. Answer: C gallstones Feedback: Cholelithiasis is commonly known as gallstones. Learning Objective: 14.04 Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 9. Answer: D gangrene Feedback: Gangrene is necrotic tissue resulting from a loss of blood supply. Learning Objective: 14.02 Topic: Conditions of the Esophagus and Stomach Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 10. Answer: D all of these could be connected to alcohol abuse

Feedback: When reading the documentation for digestive system disorders, be aware of these diagnoses which are known to be connected to alcohol abuse. If there is any indication, you might need to query the physician • Mouth cancer and gum disease: Alcohol abuse increases the risk, second only to tobacco abuse. • GERD and gastritis: Excessive use of alcohol can damage the sphincter between the esophagus and the stomach permitting stomachs acids to backwash into the esophagus. The lining of the stomach can also become irritated, • Malabsorption and malnutrition: The consistent and excessive intake of alcohol can interfere with the body's ability to absorb nutrients. • Pancreatitis: Alcohol abuse can cause inflammation in the pancreas and interfere with the proper function of the digestive process. • Alcoholic liver disease: Alcohol abuse can cause this condition, a precursor to cirrhosis. Learning Objective: 14.05 Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: When you are abstracting the documentation regarding acquired loss of teeth, you will need to identify three specified details from the notes. They are Is the loss complete or partial? What is the cause of this loss? What class classification is documented? Feedback: When you are abstracting the documentation regarding acquired loss of teeth, you will need to identify three specified details from the notes. They are Is the loss complete or partial? What is the cause of this loss? What class classification is documented? Learning Objective: 14.01 Topic: Diseases of Oral Cavity and Salivary Glands Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: Gastroesophageal Reflux Disease (GERD) Heartburn may not seem like a big concern; however, for many patients with persistent heartburn, this can be the first symptom of gasteroesophageal reflux disease (GERD). An increased intensity when bending down, lying down, or vigorous exercise. Dysphagia (difficulty with swallowing) and/or esophagitis may also occur. GERD may be caused by a slacking lower esophageal sphincter, which separates the stomach from the esophagus and designed to prevent backflow from the stomach upward. Feedback: Gastroesophageal Reflux Disease (GERD) Heartburn may not seem like a big concern; however, for many patients with persistent heartburn, this can be the first symptom of gasteroesophageal reflux disease (GERD). An increased intensity when bending down, lying down, or vigorous exercise. Dysphagia (difficulty with swallowing) and/or esophagitis may also occur. GERD may be caused by a slacking lower esophageal sphincter, which separates the stomach from the esophagus and designed to prevent backflow from the stomach upward. Learning Objective: 14.02 Topic: Conditions of the Esophagus and Stomach Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: Gastrojejunal Ulcer A lesion that develops in the small intestine can be quite problematic because it may interfere with the absorption of nutrients in the digestive process. As you review documentation for a diagnosis of a gastrojejunal ulcer, you will need to abstract some key details: Is the ulcer identified as acute or chronic? Is the ulcer hemorrhaging? Has the ulcer perforated the wall of the small intestine? Are hemorrhage and perforation both documented? If neither hemorrhage nor perforation have been documented? Feedback: Gastrojejunal Ulcer

A lesion that develops in the small intestine can be quite problematic because it may interfere with the absorption of nutrients in the digestive process. As you review documentation for a diagnosis of a gastrojejunal ulcer, you will need to abstract some key details: Is the ulcer identified as acute or chronic? Is the ulcer hemorrhaging? Has the ulcer perforated the wall of the small intestine? Are hemorrhage and perforation both documented? If neither hemorrhage nor perforation have been documented? Learning Objective: 14.03 Topic: Conditions Affecting the Intestines Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: The liver is the largest gland in the body. It‘s an almost triangularshaped organ located in the right upper quadrant (RUQ) of the abdominal cavity, beneath the diaphragm, anteriorly to the stomach and pancreas. It performs many functions including regulating blood sugar levels and aiding the digestive process by secreting bile to the gallbladder. The liver cleans the blood of toxins; metabolizes proteins, fats, and carbohydrates; and manufacturers some blood proteins. Feedback: The liver is the largest gland in the body. It‘s an almost triangularshaped organ located in the right upper quadrant (RUQ) of the abdominal cavity, beneath the diaphragm, anteriorly to the stomach and pancreas. It performs many functions including regulating blood sugar levels and aiding the digestive process by secreting bile to the gallbladder. The liver cleans the blood of toxins; metabolizes proteins, fats, and carbohydrates; and manufacturers some blood proteins. Learning Objective: 14.04 Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5.

Answer: Alcohol abuse can increase the risk of developing several serious disorders of the digestive system. When the documentation includes a connection of alcohol abuse in the diagnosis, you will need to report this with an additional code. When reading the documentation for digestive system disorders, be aware of these diagnoses which are known to be connected to alcohol abuse. If there is any indication, you might need to query the physician • Mouth cancer and gum disease: Alcohol abuse increases the risk, second only to tobacco abuse. • GERD and gastritis: Excessive use of alcohol can damage the sphincter between the esophagus and the stomach permitting stomachs acids to backwash into the esophagus. The lining of the stomach can also become irritated, • Malabsorption and malnutrition: The consistent and excessive intake of alcohol can interfere with the body's ability to absorb nutrients. • Pancreatitis: Alcohol abuse can cause inflammation in the pancreas and interfere with the proper function of the digestive process. • Alcoholic liver disease: Alcohol abuse can cause this condition, a precursor to cirrhosis. Feedback: Alcohol abuse can increase the risk of developing several serious disorders of the digestive system. When the documentation includes a connection of alcohol abuse in the diagnosis, you will need to report this with an additional code. When reading the documentation for digestive system disorders, be aware of these diagnoses which are known to be connected to alcohol abuse. If there is any indication, you might need to query the physician • Mouth cancer and gum disease: Alcohol abuse increases the risk, second only to tobacco abuse. • GERD and gastritis: Excessive use of alcohol can damage the sphincter between the esophagus and the stomach permitting stomachs acids to backwash into the esophagus. The lining of the stomach can also become irritated, • Malabsorption and malnutrition: The consistent and excessive intake of alcohol can interfere with the body's ability to absorb nutrients. • Pancreatitis: Alcohol abuse can cause inflammation in the pancreas and interfere with the proper function of the digestive process. • Alcoholic liver disease: Alcohol abuse can cause this condition, a precursor to cirrhosis. Learning Objective: 14.05 Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium

Est Time: 3-5 minutes You Code It! Basics 1. Answer: Caries, K02.52 Feedback: Dental caries on pit and fissure surface, penetrating into dentin: Caries, K02.52 K02.52: Index>caries>dental>pit and fissure surface>penetrating into dentin Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 2. Answer: Periodontitis, K05.223 Feedback: Acute generalized periodontitis: Periodontitis, K05.223 K05.223: Index>periodontitis>acute>generalized>severe Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy

Est Time: 3-5 minutes 3. Answer: Cyst, K09.0 Feedback: Odontogenic cyst: Cyst, K09.0 K09.0: Index>cyst>odontogenic Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 4. Answer: Cheilitis, K14.0 Feedback: Exfoliative cheilitis: Cheilitis, K14.0 K14.0: Index>cheilitis (exfoliative) Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 5.

Answer: Leukoplakia, K14.21 Feedback: Leukoplakia of oral mucosa: Leukoplakia, K14.21 K14.21: Index>leukoplakia>oral epithelium, including tongue (mucosa) Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 6. Answer: Hypertrophy, K14.3 Feedback: Hypertrophy of tongue papillae: Hypertrophy, K14.3 K14.3: Index>hypertrophy>tongue>papillae Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 7. Answer: Esophagitis, K20.0 Feedback: Eosinophilic esophagitis: Esophagitis, K20.0 K20.0: Index>esophagitis>esophagitis

Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 8. Answer: Ulcer, K25.3 Feedback: Acute gastric ulcer: Ulcer, K25.3 K25.3: Index>ulcer>stomach>acute Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 9. Answer: Gastritis, K29.20 Feedback: Alcoholic gastritis: Gastritis, K29.20 K29.20: Index>gastritis>alcoholic Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03

Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 10. Answer: Hyperplasia, K38.0 Feedback: Hyperplasia of the appendix: Hyperplasia, K38.0 K38.0: Index>hyperplasia>appendix Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 11. Answer: Hernia, K40.40 Feedback: Inguinal hernia with gangrene: Hernia, K40.40 K40.40: Index>hernia>inguinal>with>gangrene Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands

Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 12. Answer: Polyps, K51.414 Feedback: Inflammatory polyps of colon with abscess: Polyps, K51.414 K51.414: Index>polyps>colon>inflammatory>with>abscess Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 13. Answer: Colitis, K55.1 Feedback: Chronic ischemic colitis: Colitis, K55.1 K55.1: Index>colitis>ischemic>chronic Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption

Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 14. Answer: Prolapse, K62.3 Feedback: Rectal prolapse: Prolapse, K62.3 K62.3: Index>prolapse>rectum Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 15. Answer: Proctitis, K62.7 Feedback: Radiation proctitis: Proctitis, K62.7 K62.7: Index>proctitis>radiation Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes You Code It! Practice: 1. Answer: K57.40 Feedback: K57.40: Index>Diverticulitis>intestine>large>with>small>with>abscess Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: A50.52 Feedback: A50.52: Index>Hutchinson‘s>teeth Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: K44.0 Feedback: K44.0: Index>Hernia>diaphragm>with>obstruction Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: K70.31, F10.20 Feedback: K70.31: Index>Cirrhosis>alcoholic>with ascites F10.20: Index>dependence> alcohol Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes

5. Answer: K35.30 Feedback: K35.30: Index>Appendicitis>acute>with>peritonitis>localized Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: K05.01, Z72.0 Feedback: K05.01: Index>Gingivitis>acute>non-plaque induced Z72.0: Index>Tobacco>use Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: K52.0 Feedback: K52.0: Index>Gastroenteritis>due to>radiation

Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: Q39.1 Feedback: Q39.1: Index>Fistula>trachea-esophageal>congenital>with atresia of esophagus Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: K14.3 Feedback: K14.3: Index>Black>hairy tongue Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04

Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: K56.2 Feedback: K56.2: Index>Volvulus>with perforation Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: K25.3, F10.10 Feedback: K25.3: Index>Ulcer>stomach>acute F10.10: Index>Abuse>alcohol Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach

Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 12. Answer: K22.10, T39.015A Feedback: K22.10: Index>Ulcer>esophagus>due to>aspirin T39.015A: Drug table>Aspirin>adverse effect>initial encounter Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: K41.90 Feedback: K41.90: Index>Hernia>femoral>unilateral Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: K51.011, L88 Feedback: K51.011: Index>Pancolitis>with>rectal bleeding. L88: Index>Pyoderma>gangrenosum Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: K65.4 Feedback: K65.4: Index>Fibrosis>sclerosing mesenteric Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application: Application 1: UMBRELL, MORGAN Answer: K80.33 Feedback: K80.33: Index>Calculus>bile duct>with>cholangitis>acute>with>obstruction Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: SEQUEN, EUGENE Answer: K21.9 Feedback: K21.9: Index>Reflux>gastroesophageal Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: HERMAN, CONNIE Answer: K22.6 Feedback: K22.6: Index>Syndrome>Mallory-Weiss Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: GRAILLE, VAN Answer: K58.0 Feedback: K58.0: Index>Syndrome>irritable>bowel>with diarrhea Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 3-5 minutes Application 5: ELLISON, THERESA Answer: K85.90 Feedback: K85.90: Index>Pancreatitis>acute Learning Objective: 14.01 Learning Objective: 14.02 Learning Objective: 14.03 Learning Objective: 14.04 Learning Objective: 14.05 Topic: Diseases of Oral Cavity and Salivary Glands Topic: Conditions of the Esophagus and Stomach Topic: Conditions Affecting the Intestines Topic: Dysfunction of the Digestive Accessory Organs and Malabsorption Topic: Reporting the Involvement of Alcohol in Digestive Disorders Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 15 Coding Integumentary Conditions 2024 Compliant Learning Outcomes LO 15.1 Apply the guidelines for reporting conditions of the skin. LO 15.2 Analyze disorders of the nails, hair, glands, and sensory nerves. LO 15.3 Determine the specific characteristics of a lesion as they relate to coding. LO 15.4 Abstract the reasons for preventive care and report them accurately to support medical necessity.

Chapter Outline Learning Outcomes Key Terms Disorders of the Skin The Skin Dermatitis Psoriasis Pressure Ulcers Healing Pressure Ulcers Evolving Pressure Ulcers Presence of Gangrene

Disorders of the Nails, Hair, Glands, and Sensory Nerves Nails Nail Disorders Hair Disorders of the Hair Glands Eccrine Sweat Disorders Apocrine Sweat Disorders Sensory Nerves Lesions Malignant Lesions Prevention and Screenings Chapter Summary Chapter 15 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application Chapter Overview The integumentary system is more than just your skin. Your nails (fingers and toes) and your hair are also included, as well as sensory receptors, sebaceous (oil) glands, and sweat glands. Together, these additional components are known as accessory structures of the skin. With all the advertising about lotions to preserve youthful skin, shampoos and conditioners for soft hair, and manicures and pedicures for nails, you may forget that the elements of the integumentary system (skin, hair, nails) are not just cosmetic or decorative elements of our bodies. In addition, the glands embedded in the skin support the ongoing proper function of the body. Discussion Activities 5.

Discuss the causes of pressure ulcers and why they are such a concern, especially for patients who have mobility difficulties. Create a scenario about a patient with a pressure ulcer and include the code or codes necessary to accurately report the diagnosis. [Learning Outcome: 15.1]

Be certain students include details about the stages of pressure ulcers and the reasons why they present such a danger. These include: infection, pain, necrosis.

6.

Choose a disease or condition that affects a sebaceous gland, eccrine gland, or apocrine gland. List the signs and symptoms that would lead to a confirmed diagnosis, and include the correct code or codes. [Learning Outcome: 15.2]

These conditions include sweat disorders such as focal hyperhidrosis, Frey’s syndrome, anhidrosis, bromhidrosis. Codes are typically found in L74 and L75 code categories.

Additional Resources Common Skin Rashes (slide show) (Mayo Clinic): http://www.mayoclinic.org/skin-rash/sls-20077087 44 Common Skin Disorders (with pictures): http://www.healthline.com/health/skin-disorders Skin Conditions (MedlinePlus): http://www.nlm.nih.gov/medlineplus/skinconditions.html

Grey’s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman’s Medical Dictionary: http://www.stedmans.com/ AAPC: http://www.aapc.com American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org American Medical Association: http://www.ama-assn.org

ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 15 Review Answer Key Let’s Check It! Terminology Part I Answer: 1. A Blister 2. L Pressure Ulcer 3. F Gangrene 4. K Subcutaneous 5. B Carbuncle 6. C Decubitus Ulcer 7. H Hair Follicle 8. I Phalanges 9. G Hair 10. E Epidermis 11. D Dermis 12. J Skin Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03

Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part II Answer: 1. K Ulcer 2. H Patch 3. G Papule 4. E Nevus 5. D Macule 6. F Nodule 7. B Cyst 8. C Furuncle 9. J Scale 10. A Bulla 11. I Pustule Learning Objective: 15.03 Topic: Lesions Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: B dermis, epidermis Feedback: The dermis is a sturdy collagenous layer that connects the epidermis to the fatty tissue layer. Learning Objective: 15.01 Topic: Disorders of the Skin Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a

CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: B L21 Feedback: Seborrheic dermatitis (category L21) includes seborrhea capitis and seborrheic infantile dermatitis, commonly affecting the scalp and face. Symptoms include itching, erythematous areas, and inflammation, characterized by lesions covered with brownish gray or yellow scales in areas in which sebaceous glands are plentiful. Learning Objective: 15.01 Topic: Disorders of the Skin Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: D D22.62 Feedback: D22.62: Index>nevus>hand>left Learning Objective: 15.03 Topic: Lesions Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: B hirsutism Feedback: Hirsutism: Women with this condition have excessive hair growth on anatomical sites where hair does not typically occur, such as the chest or chin. It is believed to be caused by an abnormal hormonal level, particularly male hormones such as testosterone. Reported with code L68.0. Learning Objective: 15.02 Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1

Level of Difficulty: 2 Medium Est Time: 1-3 minutes 5. Answer: C L55.1 Feedback: L55.1: Index>Sunburn>second degree Learning Objective: 15.01 Topic: Disorders of the Skin Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: B Eccrine glands Feedback: Eccrine glands are sweat glands that are responsible for maintaining proper body temperature by excreting sweat (water, salt, and wastes) via the pores in the skin. Production of more sweat is the reaction to cool an overheated body

Learning Objective: 15.02 Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes

7. Answer: C Merkel cell carcinoma Feedback: Merkel Cell Carcinoma (also known as Neuroendocrine Carcinoma) is a rare diagnosis. Most often found on the face and neck, it can be recognized by a bluish-red or fleshcolored nodule. This malignancy grows quickly and will metastasize quickly meaning that early diagnosis and treatment is an essential component of a positive outcome. Report this confirmed diagnosis with a code from category C4A.- Merkel cell carcinoma with an additional character or characters based on the specific anatomical site.

Learning Objective: 15.03 Topic: Lesions Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes

8. Answer: C stage 3 Feedback: Stage 3 pressure ulcer involves skin loss through and including the subcutaneous tissue. A stage 3 pressure ulcer looks like a crater with visible damage to the tissue below the skin. Full-thickness tissue loss may expose subcutaneous fatty tissue but not bone, tendon, or muscle. Learning Objective: 15.01 Topic: Disorders of the Skin Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 9. Answer: A Psoriatic arthritis mutilans Feedback: Psoriatic arthritis mutilans presents with pain, edema, and/or loss of flexibility in at least one joint. When affecting the fingers or toes, the nails may show pitting or begin to separate from the nail bed. Reported with code L40.52 Psoriatic arthritis mutilans Learning Objective: 15.01 Topic: Disorders of the Skin Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 10. Answer: B use indoor tanning beds regularly Feedback: The Centers for Disease Control and Prevention (CDC) suggests ways to protect yourself from UV rays that can cause harm: • Stay in the shade as much as possible, especially during 10 am through 4 pm. • Keep your extremities (arms and legs) with clothing • Use a wide-brimmed hat to shade and protect your head, face, neck, and ears • Wear sunglasses to protect your eyes (and reduce your risk for cataracts) • Apply sunscreen with an SPF of 15 or higher • Avoid the use of any indoor tanning beds or booths including sunlamps Learning Objective: 15.04

Topic: Prevention and Screenings Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes Let’s Check It! Guidelines: 1. Answer: ulcer, site Feedback: I.C.12.a.1 Codes from category L89, Pressure ulcer, identify the site of the pressure ulcer as well as the stage of the ulcer. Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: L89, all Feedback: I.C.12.a.1 Assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable. Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: no, stage Feedback: I.C.12.a.2 When there is no documentation regarding the stage of the pressure ulcer, assign the appropriate code for unspecified stage (L89.--9). Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: clinical, terms Feedback: I.C.12.a.3 Assignment of the pressure ulcer stage code should be guided by clinical documentation of the stage or documentation of the terms found in the Alphabetic Index. Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 1-3 minutes 5. Answer: completely Feedback: I.C.12.a.4 No code is assigned if the documentation states that the pressure ulcer is completely healed. Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: healing, documentation Feedback: I.C.12.a.5 Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record. Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: admitted, progresses, two, highest Feedback: I.C.12.a.6

If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay. Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: The two factors a professional coding specialist needs to know in order to determine the correct code(s) for a diagnosed pressure ulcer are: • Anatomical location (where on the body is the ulcer) • Depth of the lesion (also known as the stage of ulcer) Feedback: The two factors a professional coding specialist needs to know in order to determine the correct code(s) for a diagnosed pressure ulcer are: • Anatomical location (where on the body is the ulcer) • Depth of the lesion (also known as the stage of ulcer) Learning Objective: 15.01 Topic: Disorders of the Skin Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: There are four stages of pressure ulcers: • Stage I affects the epidermal layer recognized by persistent erythema (redness). A stage I pressure ulcer is visualized as a reddened area on the skin that, when pressed with the finger, is ―non-blanchable‖ (does not turn white).

• Stage II is a partial thickness loss involving both the epidermis and the dermis, sometimes a fluid-filled blister is evident. A stage II pressure ulcer shows visible blisters or forms an open sore. The tissue surrounding the sore may be red and irritated like an abrasion, blister, or a shallow crater with a red-pink wound bed. • Stage III pressure ulcer identifies skin loss through and including the subcutaneous tissue. A stage III pressure ulcer looks like a crater with visible damage to the tissue below the skin. Full thickness tissue loss may expose subcutaneous fatty tissue but not bone, tendon or muscle. • Stage IV indicates the skin layers are necrotic and the ulcer reaches down into muscle and possibly bone. Stage IV pressure ulcers have become so deep that there is damage to the muscle and bone, sometimes along with tendon and joint damage. While the depth of the ulcer will vary on the basis of anatomical site, there is full-thickness tissue loss with bone, tendon or muscle exposed. • An unstageable ulcer is NOT an unspecified stage. There are times when slough and eschar must be removed to reveal the base of the wound before the true depth, or stage, can be accurately determined. The lesion may be inaccessible covered by a wound dressing that has not been removed, a sterile blister covering the area, or other documented reason. Feedback: There are four stages of pressure ulcers: • Stage I affects the epidermal layer recognized by persistent erythema (redness). A stage I pressure ulcer is visualized as a reddened area on the skin that, when pressed with the finger, is ―non-blanchable‖ (does not turn white). • Stage II is a partial thickness loss involving both the epidermis and the dermis, sometimes a fluid-filled blister is evident. A stage II pressure ulcer shows visible blisters or forms an open sore. The tissue surrounding the sore may be red and irritated like an abrasion, blister, or a shallow crater with a red-pink wound bed. • Stage III pressure ulcer identifies skin loss through and including the subcutaneous tissue. A stage III pressure ulcer looks like a crater with visible damage to the tissue below the skin. Full thickness tissue loss may expose subcutaneous fatty tissue but not bone, tendon or muscle. • Stage IV indicates the skin layers are necrotic and the ulcer reaches down into muscle and possibly bone. Stage IV pressure ulcers have become so deep that there is damage to the muscle and bone, sometimes along with tendon and joint damage. While the depth of the ulcer will vary on the basis of anatomical site, there is full-thickness tissue loss with bone, tendon or muscle exposed. • An unstageable ulcer is NOT an unspecified stage. There are times when slough and eschar must be removed to reveal the base of the wound before the true depth, or stage, can be accurately determined. The lesion may be inaccessible covered by a wound dressing that has not been removed, a sterile blister covering the area, or other documented reason. Learning Objective: 15.01 Topic: Disorders of the Skin

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: Unstageable pressure ulcers Assignment of the code for unstageable pressure ulcer (L89.-- 0) should be based on the clinical documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined (e.g., the ulcer is covered by eschar or has been treated with a skin or muscle graft) and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma. This code should not be confused with the codes for unspecified stage (L89.--9). When there is no documentation regarding the stage of the pressure ulcer, assign the appropriate code for unspecified stage (L89.--9). Feedback: Unstageable pressure ulcers Assignment of the code for unstageable pressure ulcer (L89.-- 0) should be based on the clinical documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined (e.g., the ulcer is covered by eschar or has been treated with a skin or muscle graft) and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma. This code should not be confused with the codes for unspecified stage (L89.--9). When there is no documentation regarding the stage of the pressure ulcer, assign the appropriate code for unspecified stage (L89.--9). Learning Objective: 15.01 Topic: Disorders of the Skin Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: There are three different types of glands located within the skin: • Sebaceous glands produce an oil-rich element, known as sebum, which lays on the outer surface of the epidermis and along the hair. The substance has a waterproofing effect. • Eccrine glands are sweat glands that are responsible for maintaining proper body temperature by excreting sweat (water, salt, and wastes) via the pores in the skin.

• Apocrine glands leach out a discharge that is high in protein. Located in the axilla (armpits), anal, and genital areas, bacterium interacts with the protein and creates an odor. Feedback: There are three different types of glands located within the skin: • Sebaceous glands produce an oil-rich element, known as sebum, which lays on the outer surface of the epidermis and along the hair. The substance has a waterproofing effect. • Eccrine glands are sweat glands that are responsible for maintaining proper body temperature by excreting sweat (water, salt, and wastes) via the pores in the skin. • Apocrine glands leach out a discharge that is high in protein. Located in the axilla (armpits), anal, and genital areas, bacterium interacts with the protein and creates an odor. Learning Objective: 15.02 Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: Malignant Lesions The majority of skin lesions diagnosed are benign. However, there are certain skin lesions that are pathologically identified as malignant. Malignant Melanoma is the most deadly type of skin malignancy, causing 80% of all fatalities. The most frequently identified sites of melanoma metastases are the lymph nodes, liver, lung, and the brain. The ABCDE method is used most often to evaluate a possible site, then confirmed by a biopsy. Confirmed diagnoses will be reported with a code from the category C43.- Malignant melanoma of skin, with an additional character or characters based on the specific anatomical site. Merkel Cell Carcinoma (also known as Neuroendocrine Carcinoma) is a rare diagnosis. Most often found on the face and neck, it can be recognized by a bluish-red or flesh-colored nodule. This malignancy grows quickly and will metastasize quickly meaning that early diagnosis and treatment is an essential component of a positive outcome.Report this confirmed diagnosis with a code from category C4A.- Merkel cell carcinoma with an additional character or characters based on the specific anatomical site. Squamous Cell Carcinoma are often pink and scaly with notched or irregular borders. They have the potential to become erythematous (reddened) or ulcerated with easy bleeding. Metastasis is common, making early detection and treatment very important. Report this confirmed diagnosis with a code

from category C44.- Other and unspecified malignant melanoma of skin with an additional character or characters based on the specific anatomical site. Basal Cell Carcinoma is the most frequently seen skin malignancy, with patients aged 80 or older at highest risk. Report this confirmed diagnosis with a code from category C44.- Other and unspecified malignant melanoma of skin with an additional character or characters based on the specific anatomical site. Feedback: Malignant Lesions The majority of skin lesions diagnosed are benign. However, there are certain skin lesions that are pathologically identified as malignant. Malignant Melanoma is the most deadly type of skin malignancy, causing 80% of all fatalities. The most frequently identified sites of melanoma metastases are the lymph nodes, liver, lung, and the brain. The ABCDE method is used most often to evaluate a possible site, then confirmed by a biopsy. Confirmed diagnoses will be reported with a code from the category C43.- Malignant melanoma of skin, with an additional character or characters based on the specific anatomical site. Merkel Cell Carcinoma (also known as Neuroendocrine Carcinoma) is a rare diagnosis. Most often found on the face and neck, it can be recognized by a bluish-red or flesh-colored nodule. This malignancy grows quickly and will metastasize quickly meaning that early diagnosis and treatment is an essential component of a positive outcome.Report this confirmed diagnosis with a code from category C4A.- Merkel cell carcinoma with an additional character or characters based on the specific anatomical site. Squamous Cell Carcinoma are often pink and scaly with notched or irregular borders. They have the potential to become erythematous (reddened) or ulcerated with easy bleeding. Metastasis is common, making early detection and treatment very important. Report this confirmed diagnosis with a code from category C44.- Other and unspecified malignant melanoma of skin with an additional character or characters based on the specific anatomical site. Basal Cell Carcinoma is the most frequently seen skin malignancy, with patients aged 80 or older at highest risk. Report this confirmed diagnosis with a code from category C44.- Other and unspecified malignant melanoma of skin with an additional character or characters based on the specific anatomical site. Learning Objective: 15.03 Topic: Lesions Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Basics:

1. Answer: Carbuncle, L02.235 Feedback: Index>Carbuncle of perineum: Carbuncle, L02.235 L02.235: index>carbuncle>perineum Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 2. Answer: Lymphangitis, L03.91 Feedback: Acute lymphangitis: Lymphangitis, L03.91 L03.91: Index>lymphangitis>acute Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 3. Answer: Fistula, L05.02 Feedback: Coccygeal fistula with abscess: Fistula, L05.02 L05.02: Index>fistula>coccyx see sinus>pilonidal>with abscess Learning Objective: 15.01 Learning Objective: 15.02

Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 4. Answer: Pemphigus, L10.0 Feedback: Pemphigus vulgaris: Pemphigus, L10.0 L10.0: Index>pemphigus>vulgaris Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 5. Answer: Eczema, L20.82 Feedback: Flexural eczema: Eczema, L20.82 L20.82: Index>eczema>flexural Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 6. Answer: Seborrhea, L21.0 Feedback: Seborrhea capitis: Seborrhea, L21.0 L21.0: Index>seborrhea>capitis Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 7. Answer: Dermatitis, L24.3 Feedback: Irritant contact dermatitis due to cosmetics: Dermatitis, L24.3 L24.3: Index>dermatitis>contact>irritant>due to>cosmetics Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes

8. Answer: Psoriasis, L40.0 Feedback: Psoriasis vulgaris: Psoriasis, L40.0 L40.0: Index>psoriasis>vulgaris Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 9. Answer: Arthritis, L40.52 Feedback: Psoriatic arthritis mutilans: Arthritis, L40.52 L40.52: Index>arthritis>psoriatic Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 10. Answer: Lichen, L44.1 Feedback: Lichen nitidus: Lichen, L44.1 L44.1: Index>lichen>nitidus Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03

Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 11. Answer: Effluvium, L65.0 Feedback: Telogen effluvium: Effluvium, L65.0 L65.0: Index>effluvium>telogen Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 12. Answer: Alopecia, L63.1 Feedback: Alopecia universalis: Alopecia, L63.1 L63.1: Index>alopecia>universalis Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 13. Answer: Acne, L70.1 Feedback: Acne conglobata: Acne, L70.1 L70.1: Index>acne>coglobata Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 14. Answer: Cyst, L72.11 Feedback: Pilar cyst: Cyst, L72.11 L72.11: Index>cyst>pilar Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 15.

Answer: Vasculitis, L95.0 Feedback: Livedoid vasculitis: Vasculitis, L95.0 L95.0: Index>vasculitis>livedoid Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes You Code It! Practice: 1. Answer: L23.7, W60.XXXA, Y92.830, Y93.K1, Y99.8 Feedback: L23.7: Index>Dermatitis>contact>allergic>due to>plants, non-food W60.XXXA: External cause index>contact>plant, leaves>initial encounter Y92.830: External cause index>place of occurrence>park Y93.K1: External cause index>activity>walking>an animal Y99.8: External cause index>status>leisure activity Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: L89.022 Feedback:

L89.022: Index>Ulcer>pressure>stage 2>elbow>left Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: I96, L89.613 Feedback: I96: Index>Necrosis>skin or subcutaneous tissue NEC L89.613: Index>Ulcer>pressure>stage 3>heel>right Instructions for sequencing can be found under category L89 Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: L02.13 Feedback: L02.13: Index>Carbuncle>neck Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin

Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: D03.39 Feedback: D03.39: Index>Melanoma>in situ>eyebrow Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: L00, L49.1 Feedback: L00: Index>Syndrome>staphylococcal scalded skin L49.1: Index>Exfoliation>due to erythematous>14% Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: L03.211, B95.62 Feedback: L03.211: Index>Cellulitis>face B95.62: Index>Infection>staphylococcal>as cause of disease classified elsewhere>methicillin resistant Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: L02.223, B95.8 Feedback: L02.223: Index>Furuncle>chest wall B95.8: Index>Infection>staphylococcal>as cause of disease classified elsewhere Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium

Est Time: 3-5 minutes 9. Answer: L20.83 Feedback: L20.83: Index>Eczema>infantile Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: L43.1 Feedback: L43.1: Index>Lichen>planus>bullous Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: C44.311 Feedback: C44.311: Neoplasm table>nose>skin>basal cell carcinoma Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04

Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: L40.1 Feedback: L40.1: Index>Psoriasis>pustular Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: I83.012, L97.213 Feedback: I83.012: Index>Ulcer>stasis see varix>leg>right>with>ulcer>calf L97.213: Index>Ulcer>lower limb>calf>right>with>muscle necrosis Instructions to use additional code can be found under category I83 Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: L75.2 Feedback: L75.2: Index>Miliria>apocrine Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: C43.71 Feedback: C43.71: Index>Melanoma>skin>ankle>right Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application:

Application 1: CHILDERS, AARON Answer: M02.371, M02.372, L86 Feedback: M02.371: Index>Reiter‘s disease>foot joint>right M02.372: Index>Reiter‘s disease>foot joint>left L86: Index>Keratoderma>acquired in diseases classified elsewhere Instructions for sequencing can be found under category L86 Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: STEEVANG, BRANDON Answer: B86, B20 Feedback: B86: Index>Scabies B20: Index>Human>immunodeficiency Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: CHARLES, RICHARD

Answer: B00.1 Feedback: B00.1: Index>Herpes>labialis Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: MEDINA, LEAH Answer: T63.311A, Y92.018 Feedback: T63.311A: Table of Drugs and Chemicals>venom>spider>black widow>poisoning, accidental Y92.018: External cause of injuries index>place of occurrence >residence>house, single family>specified NEC Learning Objective: 15.01 Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: CHABANNI, LORI Answer: L88 Feedback: L88: Index>Pyoderma>gangrenosum Learning Objective: 15.01

Learning Objective: 15.02 Learning Objective: 15.03 Learning Objective: 15.04 Topic: Disorders of the Skin Topic: Disorders of the Nails, Hair, Glands, and Sensory Nerves Topic: Lesions Topic: Prevention and Screenings Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 16 Coding Muscular and Skeletal Conditions 2024 Compliant Learning Outcomes

LO 16.1 Code accurately arthropathic conditions of the muscles. LO 16.2 Determine the proper way to report dorsopathies and spondylopathies. LO 16.3 Interpret the details required to report soft tissue disorders. LO 16.4 Identify the specifics of diseases that affect the musculoskeletal system reported from other areas of ICD-10-CM. LO 16.5 Report diagnoses related to pathological fractures accurately. Chapter Outline Learning Outcomes Key Terms Arthropathies Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Vertebrae Conditions Affecting the Spine Soft Tissue Disorders Musculoskeletal Disorders from Other Body Systems Acquired Conditions Congenital Disorders Pathological Fractures Chapter Summary

Chapter 16 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application Chapter Overview As you lift your hand to turn a page in this book (whether paper or electronic), your muscles are controlling the bones of your arm and hand to make the motion. Raising your leg to take a step up on a staircase or to kick a ball is also a function of your muscles. And nodding your head up and down in agreement is, again, made possible by your muscles. The human body has more than 600 muscles, ligaments, tendons, and connective tissues—the components of the muscular system. When muscle strength or action is abnormal, it can dramatically affect an individual’s quality of life. Walking, talking, sitting, and turning your head are only a few of the uses of muscles, in conjunction with other anatomical sites. In your work as a professional coding specialist, it is important to abstract from the documentation details regarding the site of the disease or injury (the specific muscle) as well as the laterality (right side or left side), when applicable. The 206 bones of the adult human skeleton provide the foundational structure for the components of the body. These bones protect internal organs as well as enable certain functions. Each bone is categorized by its shape: long bones, flat bones, short bones, irregularly shaped bones, and sesamoid bones. Any of these bones can be afflicted by malformation during gestation (congenital conditions), disease (pathologic conditions), or injury (traumatic conditions). In your job as a professional coding specialist, it is important to abstract from the documentation details regarding the site of the disease or injury (the specific bone) as well as the laterality (right side or left side), when applicable.

Discussion Activities 7.

Create a scenario about a patient with a traumatic muscle injury. Include the code or codes required to report for this encounter. [Learning Outcomes: 16.4]

Remind students that they will need external cause codes in addition to the code for the specific injury.

8.

Identify a disease that might affect the skeletal system. Create a scenario including the signs and symptoms of a pathologic condition and include the code or codes used to report this diagnosis. [Learning Outcome: 16.5]

Remind students that two codes may be needed—one to report the etiology (underlying condition) and the second to identify the specific effect on the bone.

Additional Resources Muscle Disorders (MedlinePlus):

http://www.nlm.nih.gov/medlineplus/muscledisorders.html Muscle Spasms Related Diseases & Conditions (MedicineNet.com): http://www.medicinenet.com/muscle_spasms/related-conditions/index.htm Types of Muscular Dystrophy and Neuromuscular Diseases (Johns Hopkins): http://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/types_of_muscular_d ystrophy_and_neuromuscular_diseases_85,P00792/

Grey’s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman’s Medical Dictionary: http://www.stedmans.com/ AAPC: http://www.aapc.com American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org American Medical Association: http://www.ama-assn.org

ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm

CHAPTER 16 REVIEW ANSWER KEY Let’s Check It! Terminology Answer: 1. B Intervertebral Disc 2. A Articulation 3. D Site 4. E Vertebra 5. C Laterality Learning Objective: 16.02 Learning Objective: 16.05 Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Pathological Fractures Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: B S39.012D Feedback: The correct code for a subsequent encounter for back strain is S39.012D: Index>strain>back>subsequent encounter Learning Objective: 16.02

Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: C Rheumatoid arthritis Feedback: Rheumatoid arthritis is an autoimmune systemic inflammatory disease that affects joints as well as the surrounding muscles, tendons, and ligaments. Learning Objective: 16.01 Topic: Arthropathies Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: D osteoarthritis Feedback: Osteoarthritis is a chronic degeneration of the articular cartilage simultaneous with the formation of bone spurs on the underlying bone within a joint. The cause of the osteoarthritis might be an idiomatic condition (such as code M17.11 Unilateral primary osteoarthritis, right knee); secondary to another underlying condition (such as code M18.52 Other unilateral secondary osteoarthritis of first carpometacarpal joint, left hand); or post-traumatic (such as code M19.172 Post-traumatic osteoarthritis, left ankle and foot). Learning Objective: 16.01 Topic: Arthropathies Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 4. Answer: D Torticollis

Feedback: Torticollis is a condition in which the sternocleidomastoid muscles become spasmed (shortened), causing the head to bend to one side and the chin to the opposite side. This condition may be congenital or acquired. Use code M43.6 Torticollis, or Q68.0 Congenital (sternomastoid) torticollis.

Learning Objective: 16.03 Topic: Soft Tissue Disorders Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: C M40.03 Feedback: The correct code for cervical kyphosis is M40.03 M40.03: Index>kyphosis>postural>cervicothoracic Learning Objective: 16.02 Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: D dermatopolymyositis Feedback: Dermatopolymyositis is a systemic rheumatic disorder characterized by inflammatory and degenerative changes in the skin and muscles. The first sign is often an erythematous rash that appears on the face, neck, torso (front and back), and upper extremities. In addition, a heliotropic rash on the eyelids along with periorbital edema. To report this diagnosis accurately, you will need to abstract from the documentation the involvement of the respiratory system (M33.11), myopathy (M33.12), or other specific organs being hampered by this condition (M33.19). Learning Objective: 16.03 Topic: Soft Tissue Disorders Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy

Est Time: 0-1 minute 7. Answer: A G71.11 Feedback: The correct code for myotonic muscular dystrophy is G71.11 G71.11: Index>dystrophy>muscular>myotonic Learning Objective: 16.04 Topic: Musculoskeletal Disorders from Other Body Systems Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 8. Answer: B Myasthenia gravis Feedback: Myasthenia gravis is a chronic autoimmune condition that causes muscle weakness, primarily in the face and neck, due to the immune system incorrectly attacking the muscle cells in the body. It may progress and involve additional weakness in the muscles of the extremities (arms and legs). Use code G70.00 Myasthenia gravis without (acute) exacerbation or G70.01 Myasthenia gravis with (acute) exacerbation Learning Objective: 16.04 Topic: Musculoskeletal Disorders from Other Body Systems Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 9. Answer: C P Feedback: Use a seventh character A for the entire scope of time that the patient is receiving active treatment for this fracture. This seventh character reports A the status of 'active treatment', not the relationship between physician and patient (new patient). Once the patient has completed active treatment, this character should be D reported to identify follow-up for routine healing The seventh character G would be reported for subsequent care for a G pathologic fracture with delayed healing K Subsequent care provided for a nonunion would be identified with a seventh

character of K When a malunion occurs, this subsequent care would be reported with P seventh character of P Care for any sequela (late effect) of the original pathologic fracture is S identified with a seventh character of S Learning Objective: 16.05 Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 10. Answer: D pathologic Feedback: Your bones are, typically, the strongest parts of our bodies. However, in some cases, disease can deteriorate the structure of a bone so much that it breaks under the slightest pressure. Even normal activity can result in the weakened part of the bone to break (fracture). When this happens, it is known as a pathologic fracture. Learning Objective: 16.05 Topic: Pathological Fractures Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Guidelines 1. Answer: site, laterality, represents Feedback: I.C.13.a Most of the codes within Chapter 13 have site and laterality designations. The site represents the bone, joint or the muscle involved. Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies

Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: no, one, multiple Feedback: I.C.13.a For categories where no multiple site code is provided and more than one bone, joint or muscle is involved, multiple codes should be used to indicate the different sites involved. Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: affected, joint, bone Feedback: I.C.13.a.1 For certain conditions, the bone may be affected at the upper or lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis, M80, M81). Though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint. Learning Objective: 16.01 Learning Objective: 16.02

Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: healed Feedback: I.C.13.b Bone, joint or muscle conditions that are the result of a healed injury are usually found in chapter 13. Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: A, active Feedback: I.C.13.c 7th character A is for use as long as the patient is receiving active treatment for the fracture. Learning Objective: 16.01

Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 6. Answer: systemic, musculoskeletal Feedback: I.C.13.d Osteoporosis is a systemic condition, meaning that all bones of the musculoskeletal system are affected. Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 7. Answer: without, not, fracture Feedback: I.C.13.d.1

Category M81, Osteoporosis without current pathological fracture, is for use for patients with osteoporosis who do not currently have a pathologic fracture due to the osteoporosis, even if they have had a fracture in the past. Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 8. Answer: history, Z87.310 Feedback: I.C.13.d.1 For patients with a history of osteoporosis fractures, status code Z87.310, Personal history of (healed) osteoporosis fracture, should follow the code from M81. Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

9. Answer: current, time Feedback: I.C.13.d.2 Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathologic fracture at the time of an encounter. Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 10. Answer: traumatic, known Feedback: I.C.13.d.2 A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone. Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 3-5 minutes Let’s Check It! Rules and Regulations: 1. Answer: Injuries are not the only concern that can affect an individual‘s musculoskeletal health. Diseases, infections, and other problems can occur. There are pathogens (bacteria, viruses, and fungi) that directly attack the muscles of the body. The physician‘s notes might identify the patient‘s condition as myopathy, arthropathy, chondropathy, dorsopathy, or spondylopathy. Some of these conditions are described in this list: Rheumatoid arthritis (RA) is an autoimmune systemic inflammatory disease that affects joints as well as the surrounding muscles, tendons, and ligaments. Report a code from category M05 Rheumatoid arthritis with rheumatoid factor, or M06 Other rheumatoid arthritis. To determine the complete valid code, you will need to identify, from the documentation, the specific anatomical site. Be alert because more than one anatomical site may be involved, and ICD-10-CM provides you with combination codes to report the complete story of this patient's condition. Genu recurvatum, the backward curving of the knee joint, as well as other bowing of the long bones of the leg, may be treated with braces, casting, and/or orthotics. Congenital genu recurvatum is reported with code Q68.2 Congenital deformity of knee. When this condition is the sequela (late effect) of rickets, it is reported with M21.26- Flexion deformity, knee, followed by code E64.3 Sequela of rickets. Gout, also known as gouty arthritis, is the result of the buildup of uric acid in the body. Caused by either a malfunction that produces too much uric acid or an anomaly that makes it difficult for the body to get rid of uric acid. The specific underlying cause may be idiopathic or secondary, as a manifestation of renal impairment, adverse reaction to a drug, or a toxic effect. Gout presents in the joints, most often a toe, knee, or ankle, and begins with a throbbing or extreme pain in the middle of the night. The joint will be tender, warm to the touch, and erythematous (red). The most common treatment is a prescription for NSAIDs (nonsteroidal anti-inflammatory drugs). In ICD-10-CM, gout is reported from code category M10- Gout or from code category M1A- Chronic Gout, with additional characters required to report the underlying cause (i.e., drug-induced, idiopathic, etc.) as well as the specific anatomical location (i.e., ankle, elbow, foot, etc.). Osteoarthritis is a chronic degeneration of the articular cartilage simultaneous with the formation of bone spurs on the underlying bone within a joint. The cause of the osteoarthritis might be an idiomatic condition (such as code M17.11 Unilateral primary osteoarthritis, right knee); secondary to another underlying condition (such as code M18.52 Other unilateral secondary osteoarthritis of first carpometacarpal joint, left hand); or post-traumatic (such

as code M19.172 Post-traumatic osteoarthritis, left ankle and foot). Treatments typically begin with NSAIDs and/or corticosteroid injections. In some cases, a brace or crutches may be helpful. Systemic lupus erythematosus (SLE) is an autoimmune disease affecting the joints, kidneys, brain, skin, and other organs. Interestingly, ICD-10-CM places this code category within the musculokeletal system chapter. SLE may be an adverse effect of certain drugs. When this is documented, you will code M32.0 Drug-induced systemic lupus erythematosus, as well as an additional external cause code to identify the specific drug involved. If the etiology of the SLE is unknown, you will need to abstract from the physician's notes if any organ or organ system is specifically affected. When this is documented, use a combination code from sub-category M32.1Feedback: Injuries are not the only concern that can affect an individual‘s musculoskeletal health. Diseases, infections, and other problems can occur. There are pathogens (bacteria, viruses, and fungi) that directly attack the muscles of the body. The physician‘s notes might identify the patient‘s condition as myopathy, arthropathy, chondropathy, dorsopathy, or spondylopathy. Some of these conditions are described in this list: Rheumatoid arthritis (RA) is an autoimmune systemic inflammatory disease that affects joints as well as the surrounding muscles, tendons, and ligaments. Report a code from category M05 Rheumatoid arthritis with rheumatoid factor, or M06 Other rheumatoid arthritis. To determine the complete valid code, you will need to identify, from the documentation, the specific anatomical site. Be alert because more than one anatomical site may be involved, and ICD-10-CM provides you with combination codes to report the complete story of this patient's condition. Genu recurvatum, the backward curving of the knee joint, as well as other bowing of the long bones of the leg, may be treated with braces, casting, and/or orthotics. Congenital genu recurvatum is reported with code Q68.2 Congenital deformity of knee. When this condition is the sequela (late effect) of rickets, it is reported with M21.26- Flexion deformity, knee, followed by code E64.3 Sequela of rickets. Gout, also known as gouty arthritis, is the result of the buildup of uric acid in the body. Caused by either a malfunction that produces too much uric acid or an anomaly that makes it difficult for the body to get rid of uric acid. The specific underlying cause may be idiopathic or secondary, as a manifestation of renal impairment, adverse reaction to a drug, or a toxic effect. Gout presents in the joints, most often a toe, knee, or ankle, and begins with a throbbing or extreme pain in the middle of the night. The joint will be tender, warm to the touch, and erythematous (red). The most common treatment is a prescription for NSAIDs (nonsteroidal anti-inflammatory drugs). In ICD-10-CM, gout is reported from code category M10- Gout or from code category M1A- Chronic Gout, with additional characters required to report the underlying cause (i.e., drug-induced, idiopathic, etc.) as well as the specific anatomical location (i.e., ankle, elbow, foot, etc.).

Osteoarthritis is a chronic degeneration of the articular cartilage simultaneous with the formation of bone spurs on the underlying bone within a joint. The cause of the osteoarthritis might be an idiomatic condition (such as code M17.11 Unilateral primary osteoarthritis, right knee); secondary to another underlying condition (such as code M18.52 Other unilateral secondary osteoarthritis of first carpometacarpal joint, left hand); or post-traumatic (such as code M19.172 Post-traumatic osteoarthritis, left ankle and foot). Treatments typically begin with NSAIDs and/or corticosteroid injections. In some cases, a brace or crutches may be helpful. Systemic lupus erythematosus (SLE) is an autoimmune disease affecting the joints, kidneys, brain, skin, and other organs. Interestingly, ICD-10-CM places this code category within the musculokeletal system chapter. SLE may be an adverse effect of certain drugs. When this is documented, you will code M32.0 Drug-induced systemic lupus erythematosus, as well as an additional external cause code to identify the specific drug involved. If the etiology of the SLE is unknown, you will need to abstract from the physician's notes if any organ or organ system is specifically affected. When this is documented, use a combination code from sub-category M32.1Learning Objective: 16.01 Topic: Arthropathies Blooms: Apply CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: Conditions Affecting the Spine Kyphosis is a bending forward of the vertebral column, most often at the thoracic vertebrae. This condition may be congenital or may be caused by poor posture or other spinal disorder. Kyphosis used to be commonly referred to as ―dowager‘s hump.‖ A brace and exercise are often the first course of treatment. Spinal arthrodesis may relieve symptoms, and surgery may be done when neurologic function is impaired. This condition is reported with code M40.04 Postural kyphosis, thoracic region. However, multiple codes are available for kyphosis determined by section of the spine as well as underlying cause. Scoliosis is similar to kyphosis, in that it results in a bending of the spinal column, however, with scoliosis, the bend is sideways rather than forward. The spine might resemble the letter S or C. Scoliosis is most often diagnosed in children aged 0-18, and more likely in females than males. Uneven gait and unbalanced hips and/or shoulders are signs that initiate further investigation.

Infantile idiopathic scoliosis is identified prior to the age of 4, equally in boys and girls, and more than 90% of these cases resolve without medical treatment. Juvenile idiopathic scoliosis is diagnosed in children between the ages of 4 and 10, and more often found more frequently in males than females. The curve in these children is often left-sided. Adolescent idiopathic scoliosis is seen in patients aged 10 - 18, and may be evidenced in as high as 4% of this portion of the population. Researchers believe there may be a genetic connection, however, this has not yet been proven. Spinal ankylosis is the fusion within a vertebral joint caused by disease. This is not a procedure where the physician may fuse a joint. Code sub-category M43.2 Fusion of spine requires a fifth character to report the specific region affected. Ankylosing spondylitis (AS) is actually a type of inflammation within the vertebral joint (arthritis). This may also be seen in the joints between the spine and the pelvic girdle. AS affects men more than women. Code category M45 Ankylosing spondylitis is used to report AS, with a fourth character to specify the region affected. Intervertebral disc infection is caused by a pathogen and is different from the inflammation of arthritis because it is suppurative (produces pus). Code subcategory M46.3 Infection of intervertebral disc (pyogenic) requires a fifth character to identify the specific region where the infection is located, as well as an additional code from B95-B97 to identify the pathogen. Feedback: Conditions Affecting the Spine Kyphosis is a bending forward of the vertebral column, most often at the thoracic vertebrae. This condition may be congenital or may be caused by poor posture or other spinal disorder. Kyphosis used to be commonly referred to as ―dowager‘s hump.‖ A brace and exercise are often the first course of treatment. Spinal arthrodesis may relieve symptoms, and surgery may be done when neurologic function is impaired. This condition is reported with code M40.04 Postural kyphosis, thoracic region. However, multiple codes are available for kyphosis determined by section of the spine as well as underlying cause. Scoliosis is similar to kyphosis, in that it results in a bending of the spinal column, however, with scoliosis, the bend is sideways rather than forward. The spine might resemble the letter S or C. Scoliosis is most often diagnosed in children aged 0-18, and more likely in females than males. Uneven gait and unbalanced hips and/or shoulders are signs that initiate further investigation. Infantile idiopathic scoliosis is identified prior to the age of 4, equally in boys and girls, and more than 90% of these cases resolve without medical treatment. Juvenile idiopathic scoliosis is diagnosed in children between the ages of 4 and 10, and more often found more frequently in males than females. The curve in these children is often left-sided.

Adolescent idiopathic scoliosis is seen in patients aged 10 - 18, and may be evidenced in as high as 4% of this portion of the population. Researchers believe there may be a genetic connection, however, this has not yet been proven. Spinal ankylosis is the fusion within a vertebral joint caused by disease. This is not a procedure where the physician may fuse a joint. Code sub-category M43.2 Fusion of spine requires a fifth character to report the specific region affected. Ankylosing spondylitis (AS) is actually a type of inflammation within the vertebral joint (arthritis). This may also be seen in the joints between the spine and the pelvic girdle. AS affects men more than women. Code category M45 Ankylosing spondylitis is used to report AS, with a fourth character to specify the region affected. Intervertebral disc infection is caused by a pathogen and is different from the inflammation of arthritis because it is suppurative (produces pus). Code subcategory M46.3 Infection of intervertebral disc (pyogenic) requires a fifth character to identify the specific region where the infection is located, as well as an additional code from B95-B97 to identify the pathogen. Learning Objective: 16.02 Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Blooms: Apply CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: Osteochondrosis, also known as osteochondropathy or Osgood-Schlatter disease, is a painful separation of the epiphysis of the tibial tubercle from the tibial shaft. This condition most often affects preteen and early teenage boys after a traumatic event. Treatments include immobilization of the knee and rest. In severe cases, surgical repair may be required. One code example is M93.1 Kienbock‘s disease of adults (adult osteochondrosis of carpal lunates).

Osteoporosis is a disease that is believed to be the manifestation of slowing bone formation that occurs simultaneously with an increase in the body‘s reabsorption of bone. One exception is post-traumatic osteoporosis, also known as Sudeck’s atrophy. The existence of osteoporosis increases the patient‘s susceptibility to fractures. The presence of a pathologic fracture will change the code determination in ICD-10-CM. Code category M80 reports osteoporosis with a current pathologic fracture, while code category M81 reports osteoporosis without a current pathologic fracture. Feedback:

Osteochondrosis, also known as osteochondropathy or Osgood-Schlatter disease, is a painful separation of the epiphysis of the tibial tubercle from the tibial shaft. This condition most often affects preteen and early teenage boys after a traumatic event. Treatments include immobilization of the knee and rest. In severe cases, surgical repair may be required. One code example is M93.1 Kienbock‘s disease of adults (adult osteochondrosis of carpal lunates). Osteoporosis is a disease that is believed to be the manifestation of slowing bone formation that occurs simultaneously with an increase in the body‘s reabsorption of bone. One exception is post-traumatic osteoporosis, also known as Sudeck’s atrophy. The existence of osteoporosis increases the patient‘s susceptibility to fractures. The presence of a pathologic fracture will change the code determination in ICD-10-CM. Code category M80 reports osteoporosis with a current pathologic fracture, while code category M81 reports osteoporosis without a current pathologic fracture. Learning Objective: 16.03 Topic: Soft Tissue Disorders Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: Acquired Conditions Muscle tumors do not occur frequently and can often be malignant. Use code categories C49 Malignant neoplasm of other connective and soft tissue (including muscles, bursae, ligaments, and tendons); C79.89 Secondary malignant neoplasms of other specified sites; or D21 Other benign neoplasms of connective and other soft tissue (including muscles, bursae, ligaments, and tendons). Duchenne’s muscular dystrophy (DMD) is caused by a mutation of the DMD gene within the X chromosome, resulting in the body‘s inability to create the dystrophin protein within the muscles. Due to this, males are more likely to contract the condition because females have an additional X chromosome that may counteract the mutated gene, as long as the second X chromosome is not damaged as well. Initial signs and symptoms of DMD include leg muscle weakness followed by weakness of the shoulder muscles. DMD is most often diagnosed in early childhood and may be terminal by age 21 should the weakness spread to either heart or respiratory muscles. New trials using gene therapy are hopeful. Use code G71.0 Muscular dystrophy. Myasthenia gravis is a chronic autoimmune condition that causes muscle weakness, primarily in the face and neck, due to the immune system incorrectly attacking the muscle cells in the body. It may progress and involve

additional weakness in the muscles of the extremities (arms and legs). Use code G70.00 Myasthenia gravis without (acute) exacerbation or G70.01 Myasthenia gravis with (acute) exacerbation. Paralytic syndromes are conditions in which muscle control is reduced or nonexistent. Cerebral palsy (code category G80), hemiplegia and hemiparesis (code category G81), and paraplegia (code category G82) are some of the conditions that may interfere with the activities of daily living. Congenital Disorders Congenital myopathies include minicore disease, nemaline myopathy, and fiber-type disproportion. One code, G71.2, reports several muscle abnormalities diagnosed in a neonate or infant. Most often, the infant will not meet normal developmental milestones, particularly those involving muscular actions, such as sitting up or rolling over. Such babies may also have problems feeding. Developmental dysplasia of the hip (DDH), also known as congenital hip dysplasia, is most common in a baby born breech, a large neonate, or a multiparity baby. DDH is a condition in which the head of the femur is displaced from the acetabulum. Use code Q65.89 Other specified congenital deformities of hip (congenital acetabular dysplasia). Ectromelia or hemimelia can occur in either the upper or lower limb. Ectromelia is the congenital absence or imperfection of one or more limbs. Hemimelia is a congenital abnormality affecting only the distal segment of either the upper or lower limb. This condition is reported with code Q73.8 Other reduction defects of unspecified limb (ectromelia of limb NOS) (hemimelia of limb NOS). Klippel-Feil syndrome is a condition characterized by the development of a short, wide neck due to either an abnormal number of cervical vertebrae or fused hemivertebrae (the incomplete development of one side of a vertebra). Use code Q76.1 Klippel-Feil syndrome (cervical fusion syndrome). Spina bifida is a condition in which the bony encasement of the spinal cord fails to close. Surgical repair is done as soon as possible in an effort to reduce serious handicaps. There have been some successful cases of in utero surgical repair. This condition is reported from code category Q05- Spina bifida, with an additional character to identify the specific area of the spine that is affected. Feedback: Acquired Conditions Muscle tumors do not occur frequently and can often be malignant. Use code categories C49 Malignant neoplasm of other connective and soft tissue (including muscles, bursae, ligaments, and tendons); C79.89 Secondary malignant neoplasms of other specified sites; or D21 Other benign neoplasms of connective and other soft tissue (including muscles, bursae, ligaments, and tendons). Duchenne’s muscular dystrophy (DMD) is caused by a mutation of the DMD gene within the X chromosome, resulting in the body‘s inability to create the dystrophin protein within the muscles. Due to this, males are more likely to contract the condition because females have an additional X chromosome that may counteract the mutated gene, as long as the second X chromosome is not

damaged as well. Initial signs and symptoms of DMD include leg muscle weakness followed by weakness of the shoulder muscles. DMD is most often diagnosed in early childhood and may be terminal by age 21 should the weakness spread to either heart or respiratory muscles. New trials using gene therapy are hopeful. Use code G71.0 Muscular dystrophy. Myasthenia gravis is a chronic autoimmune condition that causes muscle weakness, primarily in the face and neck, due to the immune system incorrectly attacking the muscle cells in the body. It may progress and involve additional weakness in the muscles of the extremities (arms and legs). Use code G70.00 Myasthenia gravis without (acute) exacerbation or G70.01 Myasthenia gravis with (acute) exacerbation. Paralytic syndromes are conditions in which muscle control is reduced or nonexistent. Cerebral palsy (code category G80), hemiplegia and hemiparesis (code category G81), and paraplegia (code category G82) are some of the conditions that may interfere with the activities of daily living. Congenital Disorders Congenital myopathies include minicore disease, nemaline myopathy, and fiber-type disproportion. One code, G71.2, reports several muscle abnormalities diagnosed in a neonate or infant. Most often, the infant will not meet normal developmental milestones, particularly those involving muscular actions, such as sitting up or rolling over. Such babies may also have problems feeding. Developmental dysplasia of the hip (DDH), also known as congenital hip dysplasia, is most common in a baby born breech, a large neonate, or a multiparity baby. DDH is a condition in which the head of the femur is displaced from the acetabulum. Use code Q65.89 Other specified congenital deformities of hip (congenital acetabular dysplasia). Ectromelia or hemimelia can occur in either the upper or lower limb. Ectromelia is the congenital absence or imperfection of one or more limbs. Hemimelia is a congenital abnormality affecting only the distal segment of either the upper or lower limb. This condition is reported with code Q73.8 Other reduction defects of unspecified limb (ectromelia of limb NOS) (hemimelia of limb NOS). Klippel-Feil syndrome is a condition characterized by the development of a short, wide neck due to either an abnormal number of cervical vertebrae or fused hemivertebrae (the incomplete development of one side of a vertebra). Use code Q76.1 Klippel-Feil syndrome (cervical fusion syndrome). Spina bifida is a condition in which the bony encasement of the spinal cord fails to close. Surgical repair is done as soon as possible in an effort to reduce serious handicaps. There have been some successful cases of in utero surgical repair. This condition is reported from code category Q05- Spina bifida, with an additional character to identify the specific area of the spine that is affected. Learning Objective: 16.04 Topic: Musculoskeletal Disorders from Other Body Systems Blooms: Apply CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: A traumatic fracture is the result of a trauma caused by an external source (injury) such as a fall or car accident. A pathologic fracture is the result of a disease that has weakened the bone structure. This is important information for you to abstract from the physician‘s documentation because traumatic fractures and pathologic fractures are coded differently. Actually, they have separate listings in the alphabetic index: fracture, pathological and fracture, traumatic. Feedback: A traumatic fracture is the result of a trauma caused by an external source (injury) such as a fall or car accident. A pathologic fracture is the result of a disease that has weakened the bone structure. This is important information for you to abstract from the physician‘s documentation because traumatic fractures and pathologic fractures are coded differently. Actually, they have separate listings in the alphabetic index: fracture, pathological and fracture, traumatic. Learning Objective: 16.05 Topic: Pathological Fractures Blooms: Apply CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Basics 1. Answer: Myositis, M60.074 Feedback: Infective myositis, left foot: Myositis, M60.074 M60.074: Index>myositis>infective>lower limb>foot>left Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03

Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: Arthritis, M00.862 Feedback: Pyogenic arthritis, left knee: Arthritis, M00.862 M00.862: Index>arthritis>pyogenic>knee>left Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: Granuloma, M60.251 Feedback: Foreign body granuloma of soft tissue, right thigh: Granuloma, M60.251 M60.251: Index>granuloma>foreign body (soft tissue)>thigh>right Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03

Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: Osteoarthritis, M15.2 Feedback: Juxtaphalangeal distal osteoarthritis: Osteoarthritis, M15.2 M15.2: Index>osteoarthritis>interphalangeal>proximal (Bouchard) Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: Rupture, M62.112 Feedback: Non-traumatic rupture of muscle, left shoulder: Rupture, M62.112 M62.112: Index>rupture>muscle>non-traumatic>shoulder>left Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04

Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 6. Answer: Hallux, M20.12 Feedback: Hallux valgus, left foot: Hallux, M20.12 M20.12: Index>hallux>valgus>left Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 7. Answer: Infarction, M62.242 Feedback: Ischemic infarction of muscle, left hand: Infarction, M62.242 M62.424: Index>infarction>muscle (ischemic)>hand>left Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05

Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 8. Answer: Osteomyelitis, M27.2 Feedback: Osteomyelitis neonatal jaw: Osteomyelitis, M27.2 M27.2: Index>osteomyelitis>jaw (neonatal) Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 9. Answer: Scoliosis, M41.07 Feedback: Infantile idiopathic scoliosis, lumbosacral: Scoliosis, M41.07 M41.07: Index>scoliosis>idiopathic>infantile>lumbosacral Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies

Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 10. Answer: Contracture, M24.571 Feedback: Contracture of right ankle: Contracture, M24.571 M24.571: Index>contracture>joint>ankle>right Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard 11. Answer: Atrophy, M62.562 Feedback: 11. Atrophy of left lower leg: Atrophy, M62.562 M62.562: Index>atrophy>muscle>lower leg>left Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine)

Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard 12. Answer: Ankylosis, M24.631 Feedback: Ankylosis of right wrist: Ankylosis, M24.631 M24.631: Index>ankyloses>wrist>right Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard 13. Answer: Abscess, M65.031 Feedback: Abscess of tendon sheath, right forearm: Abscess, M65.031 M65.031: Index>abscess>tendon (sheath)>forearm>right Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard 14. Answer: Stenosis, M48.03 Feedback: Spinal stenosis, cervicothoracic region: Stenosis, M48.03 M48.03: Index>stenosis>spinal>cervicothoracic region Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard 15. Answer: Tendinitis, M65.252 Feedback: Calcific tendinitis, left pelvic region: Tendinitis, M65.252 M65.252: Index>tendinitis>calcific>pelvic region>left Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard You Code It! Practice: 1. Answer: G90.511 Feedback: G90.511: Index>Dystrophy> reflex sympathetic ~redirects us ~ Syndrome>pain>complex region I>upper limb>right Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: M75.112 Feedback: M75.112: Index>Tear>rotator cuff>incomplete>left Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: M60.052, B95.61 Feedback: M60.052: Index>Pymyositis ~ redirects us ~ Myositis>infective>lower limb>thigh>left B95.61: Index>Infection>staphylococcus>as cause of disease classified elsewhere>aureus Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: M67.51 Feedback: M67.51: Index>Plica>syndrome, knee>right Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: M12.452 Feedback: M12.452: Index>Hydrarthrosis>intermittent>hip>left Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 6. Answer: M70.22 Feedback: M70.22: Index> Bursitis>elbow>olecranon>left Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

7. Answer: G72.3 Feedback: G72.3: Index>Paralysis>periodic Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 8. Answer: M26.212 Feedback: M26.212: Index>Malocclusion>Angle‘s>class II Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 9. Answer: A92.1, M01.X52

Feedback: A92.1: Index>Arthritis>in>O‘nyong-nyong M01.X52: Index>Arthritis>due to>infectious disease NEC Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 10. Answer: M41.27 Feedback: M41.27: Index>Scoliosis>idiopathic>lumbosacral region Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 11. Answer: M72.0 Feedback: M72.0: Index>Disease>Dupuytren‘s

Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 12. Answer: M66.174 Feedback: M66.174: Index>Rupture>synovium>foot>right Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 13. Answer: M54.32 Feedback: M54.32: Index>Sciatica>wallet>left side Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03

Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 14. Answer: G24.3 Feedback: G24.3: Index>Tortocollis>spasmodic Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 15. Answer: M76.62, Y92.39, Y93.43, Y99.8 Feedback: M76.62: Index>Tendinitis>Achilles>left Y92.39: External Causes index>place of occurrence>gymnasium Y93.43: External Causes index>activity>gymnastics, rhythmic Y99.8: External Causes index>status>leisure activity Learning Objective: 16.01 Learning Objective: 16.02

Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Application: Application 1: LOPEZ, JUANA Answer: M33.22 Feedback: M33.22: Index>Polymyositis>with>myopathy Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: MARCHEON, GABRIELLA Answer: M23.211 Feedback: M23.211: Index>Derangement>meniscus>due to old tear>medial>anterior horn>right knee

Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: STRICK, JOSEPH Answer: M67.02 Feedback: M67.02: Index>short>tendon>Achilles>left Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: LAO, HANNAH Answer: M10.272, H40.10X0, T49.8X5A, T50.2X5A

Feedback: M10.272: Index>Gout>drug-induced>ankle and foot>left H40.10X0: Index>Glaucoma>open-angle>unspecified stage T49.8X5A: Table of Drugs and Chemicals>Urea>Topical>Adverse Effect T50.2X5A: Table of Drugs and Chemicals>Acetazolamide>Adverse Effect Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: BRACKSLEY, NATASHA Answer: M17.0 Feedback: M17.0: Osteoarthritis>knee>bilateral Learning Objective: 16.01 Learning Objective: 16.02 Learning Objective: 16.03 Learning Objective: 16.04 Learning Objective: 16.05 Topic: Arthropathies Topic: Dorsopathies and Spondylopathies (Conditions Affecting the Joints of the Spine) Topic: Soft Tissue Disorders Topic: Musculoskeletal Disorders from Other Body Systems Topic: Pathological Fractures Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

Chapter 17 Coding Injury, poisoning and External Causes 2024 Compliant Learning Outcomes

LO 17.1 Analyze the documentation to determine when external cause codes are required. LO 17.2 Apply guidelines for coding traumatic injuries. LO 17.3 Determine seventh characters for injury codes accurately. LO 17.4 Identify a suggested code from the Table of Drugs and Chemicals. LO 17.5 Distinguish between poisonings and adverse effects. LO 17.6 Abstract documentation to accurately report burns. LO 17.7 Demonstrate coding protocols for reporting abuse and neglect. LO 17.8 Evaluate documented complications of care to report them accurately. Chapter Outline Learning Outcomes Key Terms Reporting External Causes of Injuries Cause of the Injury Code Place of the Occurrence Code Activity Code Patient’s Status Traumatic Injuries Traumatic Fractures Types of Fractures Sequelae (Late Effects) of Fractures Traumatic Wounds Lacerations (Superficial Wounds) Contusions and Hematomas Puncture Wounds Avulsions Animal, Insect, or Human Bites Traumatic Injury to the Muscles Using Seventh Characters to Report Status of Care Using the Table of Drugs and Chemicals Drug and Chemical Names

Adverse Effects, Poisoning, Underdosing, and Toxic Effects Adverse Reaction Poisoning Underdosing and Patient Noncompliance Toxic Effects Substance Interactions Reporting Burns Site and Severity Extent Infection in the Burn Site Solar and Radiation Burns Sequelae (Late Effects) of Burns and Corrosions Abuse, Neglect, and Maltreatment Complications of Care Chapter Summary Chapter 17 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code IT! Basics You Code It! Practice You Code It! Application

Chapter Overview You have already learned about certain injuries that can occur, such as pressure ulcers (Chapter 14), muscle sprains (Chapter 15), and fractures (Chapter 17). Now, in this chapter, you will review details and directions for reporting some other injuries and types of harm. The term injury refers to traumatic damage to some aspect of the body, virtually always caused by a fall, crash, weapon, or some other external cause. The damage may be minor (superficial) or life threatening, may occur during time at work or while playing, may be the result of an automobile accident or a fight, or may occur during an indoor or outdoor activity. People burn themselves in many different ways under many different circumstances every day. Such patients may go to their family physician’s office, the emergency department, a dermatologist, or a plastic surgeon. Burn injuries may be resolved quickly or may cause pain and suffering for the patient for years, resulting in infections, scarring, and other conditions. A professional coding specialist must be able to report burn situations accurately. Individuals can come into contact with a substance that disagrees with their body chemistry for many reasons. An allergic reaction, the accidental ingestion of too many pills, depression leading to a suicide attempt,

environmental factors—any of these and more can cause a person to suffer a health-related incident. Adverse effects, poisonings, and toxic effects can be very serious to the health of an individual. Complex chemical interactions in the human body equate to complex coding processes to accurately report what has happened.

Discussion Activities 9.

Explain, in your own words, the difference between an adverse effect, a poisoning, and a toxic effect. Create a scenario for one of these situations and include the code or codes required for accurate reporting. [Learning Outcome: 17.5]

Remind students to check the Official Guidelines, 1.C.19. e. Adverse effects, poisoning, underdosing, and toxic effects.

10. Adults and children, the very young and very old, are all potential victims of abuse, neglect, and maltreatment. Explain, in your own words, how the Official Guidelines direct you to accurate coding. [Learning Outcome: 17.7] Remind students to check the Official Guidelines, 1.C.19. f. Adult and child abuse, neglect, and other maltreatment.

Additional Resources Burns (MedlinePlus): http://www.nlm.nih.gov/medlineplus/burns.html Burns (Merck Manual): http://www.merckmanuals.com/home/injuries_and_poisoning/burns/burns.html Overview of Poisoning (Merck Manual): http://www.merckmanuals.com/home/injuries_and_poisoning/poisoning/overview_of_poisoning.html Preventable Adverse Drug Reactions (FDA): http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractionsLabeling/ ucm110632.htm Adverse Drug Reactions (Merck Manual): http://www.merckmanuals.com/professional/clinical_pharmacology/adverse_drug_reactions/adverse_drug_ reactions.html Elder Abuse and Neglect (American Psychological Association): http://www.apa.org/pi/aging/resources/guides/elder-abuse.aspx

Grey’s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman’s Medical Dictionary: http://www.stedmans.com/ AAPC: http://www.aapc.com American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org American Medical Association: http://www.ama-assn.org

ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 17 Review Answer Key Let’s Check It! Terminology Part I Answer:

1. A Avulsion 2. D First-Degree Burn 3. C Corrosion 4. J Third-Degree Burn 5. B Burn 6. H Severity 7. G Second-Degree Burn 8. F Rule of Nines 9. E Laceration 10. I Site Learning Objective: 17.02 Learning Objective: 17.05 Topic: Traumatic Injuries Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part II Answer: 1. A Abuse 2. C Extent 3. E Malunion 4. B Dislocation 5. D Fracture 6. F Myalgia 7. H Physicians’ Desk Reference (PDR) 8. G Nonunion Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.05 Learning Objective: 17.06 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2

ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: C Y92.027 Feedback: Y92.027: External cause index>place of occurrence>residence>mobile home>garden Leaning Objective: 17.01 Topic: Reporting External Causes of Injuries Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 2. Answer: C Comminuted Feedback: Comminuted fracture identifies the breaking of the bone into several pieces. A closed reduction may be required prior to immobilization by cast or splint. Internal fixation may be necessary to correct an impacted fracture with an open reduction. Learning Objective: 17.02 Topic: Traumatic Injuries Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: A contusion Feedback: A contusion, commonly known as a bruise or black-and-blue mark, is an injury to the body that typically does not break the skin but does damage to the underlying blood vessels. Learning Objective: 17.02 Topic: Traumatic Injuries Blooms: Remember CAAHEP: I.C.1

CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 4. Answer: B S05.72XA Feedback: S05.72XA: Index>avulsion>eye>left>initial encounter Learning Objective: 17.02 Topic: Traumatic Injuries Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 5. Answer: D the size of the dose Feedback: Drugs and chemicals are listed in the Table of Drugs and Chemicals by brand name, chemical name and drug category. Learning Objective: 17.03 Topic: Using Seventh Characters to Report Status of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: D vodka Feedback: The Table of Drugs and Chemicals does not list individual types of alcoholic beverages. Learning Objective: 17.03 Topic: Using Seventh Characters to Report Status of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute

7. Answer: A Intentional Self-Harm Feedback: The columns in the ICD-10-CM Table of Drugs And Chemicals include: Poisoning, accidental; Poisoning, intentional self-harm; Poisoning, assault; Poisoning, undeterminded; Adverse Effect; Underdosing. Learning Objective: 17.04 Topic: Using the Table of Drugs and Chemicals Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: B contracture Feedback: Often, a scar or contracture develops at the site of a healed burn or corrosion. There are times when this lasting condition requires treatment or a procedure. In these cases, you will report the original burn or corrosion code using the seventh character ―S,‖ for sequela, to identify that the care and treatment are directed at the late effect of the burn or corrosion. Learning Objective: 17.05 Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: A T20.33XD Feedback: T20.33XD: Index>Burn>chin>third degree>subsequent encounter Learning Objective: 17.05 Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 10. Answer: C O9A.313

Feedback: O9A.313 The correct code for a pregnant woman in her third trimester who has been physically abused is O9A.313. O9A.313: Index>pregnancy>complicated by>abuse>physical>third trimester Learning Objective: 17.06 Topic: Reporting Burns Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Let’s Check It! Guidelines Part I: 1. Answer: 7th Feedback: I.C.19.a Most categories in chapter 19 have a 7th character requirement for each applicable code. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2.

Answer: Z, aftercare, subsequent Feedback: I.C.19.a The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: Superficial Feedback: I.C.19.b.1 Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects

Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: minor, primary, first Feedback: I.C.19.b.2 When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or injury to blood vessels (such as category S15). Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: initial, active Feedback: I.C.19.c.1

Traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) for each encounter where the patient is receiving active treatment for the fracture. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: severity Feedback: I.C.19.c.2 Multiple fractures are sequenced in accordance with the severity of the fracture. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: external, highest Feedback: I.C.19.d.1 When the reason for the admission or encounter is for treatment of external multiple burns, sequence first the code that reflects the burn of the highest degree. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: anatomic, degrees Feedback: I.C.19.d.2 Classify burns of the same anatomic site and on the same side but of different degrees to the subcategory identifying the highest degree recorded in the diagnosis (e.g., for second and third degree burns of right thigh, assign only code T24.311-). Learning Objective: 17.01 Learning Objective: 17.02

Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: acute Feedback: I.C.19.d.3 Non-healing burns are coded as acute burns. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: separate Feedback: I.C.19.d.5 When coding burns, assign separate codes for each burn site. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: T31, T32, extent Feedback: I.C.19.d.6 Assign codes from category T31, Burns classified according to extent of body surface involved, or T32, Corrosions classified according to extent of body surface involved, when the site of the burn is not specified or when there is a need for additional data. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries

Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 12. Answer: late, ―S‖ Feedback: I.C.19.d.7 Encounters for the treatment of the late effects of burns or corrosions (i.e., scars or joint contractures) should be coded with a burn or corrosion code with the 7th character ―S‖ for sequela. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Part II: 1.

Answer: current, sequelae Feedback: I.C.19.d.8 When appropriate, both a code for a current burn or corrosion with 7th character ―A‖ or ―D‖ and a burn or corrosion code with 7th character ―S‖ may be assigned on the same record (when both a current burn and sequelae of an old burn exist). Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: external, source Feedback: I.C.19.d.9 An external cause code should be used with burns and corrosions to identify the source and intent of the burn, as well as the place where it occurred. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care

Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: many Feedback: I.C.19.e.2 Use as many codes as necessary to describe completely all drugs, medicinal or biological substances. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: individually Feedback: I.C.19.e.4

If two or more drugs, medicinal or biological substances are reported, code each individually unless a combination code is listed in the Table of Drugs and Chemicals. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: adverse, correctly, properly Feedback: I.C.19.e.5.a When coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50). Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects

Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: improper, T36- T50 Feedback: I.C.19.e.5.b When coding a poisoning or reaction to the improper use of a medication (e.g., overdose, wrong substance given or taken in error, wrong route of administration), first assign the appropriate code from categories T36- T50. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: Underdosing Feedback: I.C.19.e.5.c Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer‘s instruction. Learning Objective: 17.01

Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: toxic Feedback: I.C.19.e.5.d When a harmful substance is ingested or comes in contact with a person, this is classified as a toxic effect. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: confirmed, assault Feedback: I.C.19.f For cases of confirmed abuse or neglect an external cause code from the assault section (X92-Y09) should be added to identify the cause of any physical injuries. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: suspected, Z04.71 Feedback: I.C.19.f If a suspected case of abuse, neglect or mistreatment is ruled out during an encounter code Z04.71, Encounter for examination and observation following alleged physical adult abuse, ruled out, or code Z04.72, Encounter for examination and observation following alleged child physical abuse, ruled out, should be used, not a code from T76. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04

Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: complication Feedback: I.C.19.g.5 Intraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs and structures of that body system. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 1-3 minutes Part III: 1. Answer: data Feedback: I.C.20 External cause codes are intended to provide data for injury research and evaluation of injury prevention strategies. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: A00.0-T88.9 Feedback: I.C.20.a.1 An external cause code may be used with any code in the range of A00.0T88.9, Z00-Z99, classification that is a health condition due to an external cause. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07

Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: encounter Feedback: I.C.20.a.2 Assign the external cause code, with the appropriate 7th character (initial encounter, subsequent encounter or sequela) for each encounter for which the injury or condition is being treated. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes

4. Answer: external, completely Feedback: I.C.20.a.3 Use the full range of external cause codes to completely describe the cause, the intent, the place of occurrence, and if applicable, the activity of the patient at the time of the event, and the patient‘s status, for all injuries, and other health conditions due to an external cause. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: never Feedback: I.C.20.a.6 An external cause code can never be a principal (first-listed) diagnosis. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals

Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: Y92 Feedback: I.C.20.b Codes from category Y92, Place of occurrence of the external cause, are secondary codes for use after other external cause codes to identify the location of the patient at the time of injury or other condition. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: once, initial Feedback: I.C.20.b Generally, a place of occurrence code is used only once, at the initial encounter for treatment. Learning Objective: 17.01

Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: Y93 Feedback: I.C.20.c Assign a code from category Y93, Activity code, to describe the activity of the patient at the time the injury or other health condition occurred. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: assault Feedback: I.C.20.g Adult and child abuse, neglect and maltreatment are classified as assault. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: ―S‖ Feedback: I.C.20.i.1 Sequela are reported using the external cause code with the 7th character ―S‖ for sequela. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries

Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: Y38.9, secondary Feedback: I.C.20.j.3 Assign code Y38.9, Terrorism, secondary effects, for conditions occurring subsequent to the terrorist event. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 12. Answer: Y99, status Feedback: I.C.20.k

Assign a code from category Y99, External cause status, to indicate the work status of the person at the time the event occurred. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: A traumatic fracture is the result of a trauma caused by an external source (injury) such as a fall or car accident. A pathologic fracture is the result of a disease that has weakened the bone structure. This is important information for you to abstract from the physician‘s documentation because traumatic fractures and pathologic fractures are coded differently. Actually, they have separate listings in the alphabetic index: fracture, pathological and fracture, traumatic. Feedback: A traumatic fracture is the result of a trauma caused by an external source (injury) such as a fall or car accident. A pathologic fracture is the result of a disease that has weakened the bone structure. This is important information for you to abstract from the physician‘s documentation because traumatic fractures and pathologic fractures are coded differently. Actually, they have separate listings in the alphabetic index: fracture, pathological and fracture, traumatic.

Learning Objective: 17.02 Topic: Traumatic Injuries Blooms: Apply CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: When a patient has suffered a burn, you have to S/S.E.E. the burn in order to code it correctly. This acronym can help you remember what details you need, the minimum number of codes you need, and what order in which to report those codes. You need at least three codes to properly report the diagnosis of a burn: First-listed code(s): S/S = site and severity (from categories T20-T25) Next listed code: E= Extent (from code category T31) Lastly, code(s): E= External cause code(s) Feedback: When a patient has suffered a burn, you have to S/S.E.E. the burn in order to code it correctly. This acronym can help you remember what details you need, the minimum number of codes you need, and what order in which to report those codes. You need at least three codes to properly report the diagnosis of a burn: First-listed code(s): S/S = site and severity (from categories T20-T25) Next listed code: E= Extent (from code category T31) Lastly, code(s): E= External cause code(s) Learning Objective: 17.05 Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Blooms: Apply CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: Using the layers of the skin, the severity of a burn is identified by degree: First degree burns are evident by erythema (redness of the epidural layer)

Second degree burns are identified by fluid-filled blisters in addition to the erythema Third degree burns have damage evident in the epidermis, dermis, and fatty tissue layers and can involve the muscles and nerves below. Deep third degree burned skin will show necrosis (death of the tissue) and at times, may result in the loss (amputation) of a body part. The fourth characters available in this section give you the ability to report the documented severity of the burn or corrosion. .0 Unspecified degree .1 Erythema (first degree) .2 Blisters, epidermal loss (second degree) .3 Full-thickness skin loss (third degree NOS) .4 Corrosion of unspecified degree .5 Corrosion of first degree .6 Corrosion of second degree .7 Corrosion of the third degree Feedback: Using the layers of the skin, the severity of a burn is identified by degree: First degree burns are evident by erythema (redness of the epidural layer) Second degree burns are identified by fluid-filled blisters in addition to the erythema Third degree burns have damage evident in the epidermis, dermis, and fatty tissue layers and can involve the muscles and nerves below. Deep third degree burned skin will show necrosis (death of the tissue) and at times, may result in the loss (amputation) of a body part. The fourth characters available in this section give you the ability to report the documented severity of the burn or corrosion. .0 Unspecified degree .1 Erythema (first degree) .2 Blisters, epidermal loss (second degree) .3 Full-thickness skin loss (third degree NOS) .4 Corrosion of unspecified degree .5 Corrosion of first degree .6 Corrosion of second degree .7 Corrosion of the third degree Learning Objective: 17.05 Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Blooms: Apply CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

4. Answer: Adult and child abuse, neglect and other maltreatment Sequence first the appropriate code from categories T74.- (Adult and child abuse, neglect and other maltreatment, confirmed) or T76.(Adult and child abuse, neglect and other maltreatment, suspected) for abuse, neglect and other maltreatment, followed by any accompanying mental health or injury code(s). If the documentation in the medical record states abuse or neglect it is coded as confirmed (T74.-). It is coded as suspected if it is documented as suspected (T76.-). For cases of confirmed abuse or neglect an external cause code from the assault section (X92-Y08) should be added to identify the cause of any physical injuries. A perpetrator code (Y07) should be added when the perpetrator of the abuse is known. For suspected cases of abuse or neglect, do not report external cause or perpetrator code. If a suspected case of abuse, neglect or mistreatment is ruled out during an encounter code Z04.71, Encounter for examination and observation following alleged physical adult abuse, ruled out, or code Z04.72, Encounter for examination and observation following alleged child physical abuse, ruled out, should be used, not a code from T76. If a suspected case of alleged rape or sexual abuse is ruled out during an encounter code Z04.41, Encounter for examination and observation following alleged physical adult abuse, ruled out, or code Z04.42, Encounter for examination and observation following alleged rape or sexual abuse, ruled out, should be used, not a code from T76. See Section I.C.15. Abuse in a pregnant patient. Feedback: Adult and child abuse, neglect and other maltreatment Sequence first the appropriate code from categories T74.- (Adult and child abuse, neglect and other maltreatment, confirmed) or T76.(Adult and child abuse, neglect and other maltreatment, suspected) for abuse, neglect and other maltreatment, followed by any accompanying mental health or injury code(s). If the documentation in the medical record states abuse or neglect it is coded as confirmed (T74.-). It is coded as suspected if it is documented as suspected (T76.-).

For cases of confirmed abuse or neglect an external cause code from the assault section (X92-Y08) should be added to identify the cause of any physical injuries. A perpetrator code (Y07) should be added when the perpetrator of the abuse is known. For suspected cases of abuse or neglect, do not report external cause or perpetrator code. If a suspected case of abuse, neglect or mistreatment is ruled out during an encounter code Z04.71, Encounter for examination and observation following alleged physical adult abuse, ruled out, or code Z04.72, Encounter for examination and observation following alleged child physical abuse, ruled out, should be used, not a code from T76. If a suspected case of alleged rape or sexual abuse is ruled out during an encounter code Z04.41, Encounter for examination and observation following alleged physical adult abuse, ruled out, or code Z04.42, Encounter for examination and observation following alleged rape or sexual abuse, ruled out, should be used, not a code from T76. See Section I.C.15. Abuse in a pregnant patient. Learning Objective: 17.06 Topic: Reporting Burns Blooms: Apply CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: Patient noncompliance is when a patient has an adverse effect because he or she did not take the medication as ordered by the physician . . . or didn‘t take the drugs at all. When too low of the quantity prescribed (known as underdosing) is the will of the patient, rather than an error on the part of a health care professional, this is considered noncompliance, and is reported with an additional code to explain intent: Z91.12- Patient’s intentional underdosing of medication regimen Z91.13- Patient’s unintentional underdosing of medication regimen Z91.14- Patient’s other noncompliance with medication regimen Feedback: Patient noncompliance is when a patient has an adverse effect because he or she did not take the medication as ordered by the physician . . . or didn‘t take the drugs at all. When too low of the quantity prescribed (known as underdosing) is the will of the patient, rather than an error on the part of a

health care professional, this is considered noncompliance, and is reported with an additional code to explain intent: Z91.12- Patient’s intentional underdosing of medication regimen Z91.13- Patient’s unintentional underdosing of medication regimen Z91.14- Patient’s other noncompliance with medication regimen Learning Objective: 17.04 Topic: Using the Table of Drugs and Chemicals Blooms: Apply CAAHEP: I.C.1 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 3.a ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Basics 1. Answer: Underdosing, T42.2X6A Feedback: Underdosing of succinimides, initial encounter: Underdosing, T42.2X6A T42.2X6A: Table of Drugs and Chemicals>succinimides>underdosing>initial encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 1-3 minutes 2. Answer: constriction, S00.242A Feedback: External constriction of left eyelid, initial encounter: Constriction, S00.242A S00.242A: Index>constriction>external>eyelid>left>initial encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: Laceration, S01.21XA Feedback: Laceration without foreign body of nose, initial encounter: Laceration, S01.21XA S01.21XA: Index>laceration>nose>initial encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care

Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: Bite, S01.452D Feedback: Open bite of left cheek, subsequent encounter: Bite, S01.452D S01.451D: Index>bite>cheek>left>subsequent encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: Corrosion, T27.4XXS Feedback: Corrosion of trachea, sequela: Corrosion, T27.4XXS T27.4XXS: Index>corrosion>trachea>sequel Learning Objective: 17.01

Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: Toxic effect, T51.0X3D Feedback: Toxic effect of ethanol, assault, subsequent encounter: Toxic effect, T51.0X3D T51.0X3D: Table of Drugs and Chemicals>ethanol>assault>subsequent encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: Puncture, S01.04XA Feedback: Puncture wound with foreign body of scalp, initial encounter: Puncture, S01.04XA S01.04XA: index>puncture>scalp>with foreign body>initial encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: Burn, T22.241A Feedback: Second degree burn of the right axilla, initial encounter: Burn, T22.241A T22.241A: Index>burn>axilla>right>second degree>initial encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07

Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: Fracture, S42.022P Feedback: Displaced shaft fracture of the left clavicle (traumatic), subsequent encounter for fracture with malunion: Fracture, S42.022P S42.022P: Index>fracture>traumatic>clavicle>shaft>displaced> subsequent encounter for fracture with malunion Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes

10. Answer: Concussion, S06.0X1A Feedback: Concussion with loss of consciousness of 28 minutes: Concussion, S06.0X1A S06.0X1A: Index>concussion>with loss of consciousness of 30 minutes or less>initial encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: Contusion, S00.432D Feedback: Contusion of left ear, subsequent encounter: Contusion, S00.432D S00.432D: Index>contusion>ear>left>subsequent encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects

Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 12. Answer: Crushing, S17.0XXA Feedback: Crushing injury of larynx: Crushing, S17.0XXA S17.0XXA: Index>crushing>larynx>initial encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 13. Answer: Corrosion, T22.752A Feedback: Corrosion of third degree of left shoulder, initial encounter: Corrosion, T22.752A T22.752A: Index>corrosion>shoulder>left>third degree>initial encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03

Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 14. Answer: Adverse effect, T37.1X5A Feedback: Adverse effect of antimycobacterial drugs, combination: Adverse effect, T37.1X5A T37.1X5A: Table of Drugs and Chemicals> antimycobacterial>combination>adverse effect>initial encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 15. Answer: Fracture, M84.561G Feedback: Pathological fracture of right tibia due to neoplastic disease, delayed healing: Fracture, M84.561G M84.561G: Index>fracture>pathological>due to neoplastic disease>tibia>subsequent encounter for fracture with delayed healing. Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes You Code It! Practice: 1. Answer: S82.231B, W21.03XA, Y92.830, Y93.64, Y99.8 Feedback: S82.231B: Index>Fracture>traumatic>tibia>oblique>right>initial encounter>open fracture type I W21.03XA: Index>External cause index>struck by>object>projected>in sports>ball> baseball>initial encounter Y92.830: External cause index>place of occurrence>park>public Y93.64: External cause index>activity>baseball Y99.8: External cause index>status>leisure activity Learning Objective: 17.01

Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: S60.521A, Y93.73, Y99.8 Feedback: S60.521A: Index>Blister>hand>right>initial encounter Y93.73: External cause index>activity>handball Y99.8: External cause index>status>leisure activity Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: S00.81XA, W09.0XXA, Y92.017, Y93.89, Y99.8 Feedback: S00.81XA: Index>Abrasion>cheek>left>initial encounter W09.0XXA: External cause index>fall, falling>from, off, out of >playground equipment>slide> initial encounter Y92.017: External cause index>place of occurrence>residence>house>yard Y93.89: External cause index>activity>specified NEC Y99.8: External cause index>status>leisure activity Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: T23.232A, T31.0, X03.0XXA, Y92.833, Y93.G9, Y99.8 Feedback:

T23.232A: Index>Burns>finger>multiple sites>left>second degree>initial encounter T31.0: Index>Burn>extent>less than 10% X03.0XXA: External cause index>burn~ redirect us to ~ exposure>fire>controlled>not in building or structure>initial encounter Y92.833: External cause index>place of occurrence>campsite Y93.G9: External cause index>activity>cooking or baking – be careful here the index gets you to the correct category, but you need to read all the subcategories to get the correct fifth digit. Y99.8: External cause index>status>leisure activity Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: S71.112A, W26.0XXA Feedback: S71.112A: Index>Laceration>thigh>left>initial encounter W26.0XXA: External cause index>contact>knife>initial encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04

Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: T50.7X4A, R40.0 Feedback: T50.7X4A: Drug table>cyclazocine>poisoning, undetermined>initial encounter R40.0: Index>Drowsiness Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes

7. Answer: S90.32XA, W22.03XA Feedback: S90.32XA: Index>Contusion>foot>left>initial encounter W22.03XA: External cause index>striking against>object>furniture>initial encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: S81.851A, W55.01XA, Y92.019 Feedback: S81.851A: Index>Bite>leg>right>initial encounter W55.01XA: External cause index>bite>cat>initial encounter Y92.019: External cause index>place of occurrence>residence>house Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries

Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: T17.290A Feedback: T17.290A: Index>Foreign body>pharynx>causing>asphyxiation>specific type NEC>initial encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: T62.1X1A, R09.89, Y92.017 Feedback:

T62.1X1A: Drug table>mezereon>berries>poisoning, accidental>initial encounter R09.89: Index>Choking sensation Y92.017: External cause index>place of occurrence>residence>house>yard Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: T74.12XA, K22.2, T54.3X3A, Y07.430 Feedback: T74.12XA: Index>Maltreatment>child>physical abuse>confirmed>initial encounter K22.2: Index>Stricture>esophagus T54.3X3A: Drug table>lye>poisoning, assault>initial encounter Y07.430: External cause index>perpetrator>stepfather Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care

Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 12. Answer: S59.222A, W21.03XA, Y92.320, Y93.64, Y99.8 Feedback: S59.222A: Index>Fracture>traumatic>radius>lower end>physeal>SalterHarris>type II> left>initial encounter W21.03XA: External cause index>struck by>object>thrown>in sports>ball>baseball>initial encounter Y92.320: External cause index>place of occurrence>sports area>athletic>field>baseball Y93.64: External cause index>activity>baseball Y99.8: External cause index>status>student activity Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 1-3 minutes 13. Answer: S72.044A, W00.1XXA, Y92.018, Y93.01, Y99.8 Feedback: S72.044A: Index>Fracture>traumatic>femur>neck~ redirects us ~ Fracture>traumatic>femur> upper end>neck>base>nondisplaced>right>initial encounter W00.1XXA: External cause index>Fall> from, off>stirs, steps>due to ice or snow>initial encounter Y92.018: External cause index>place of occurrence>residence>house, single family> specified NEC Y93.01: External cause index>activity>walking Y99.8: External cause index>status>leisure activity Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 14. Answer: T24.211A, T31.0, X10.2XXA Feedback: T24.211A: Index>Burn>thigh>right>second degree>initial encounter T31.0: Index>Burn>extent>less than 10 percent

X10.2XXA: External cause index>burn>hot>oil (cooking)>initial encounter Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 15. Answer: S93.412A, S93.432A, V00.111A, Y92.480, Y93.51, Y99.8 Feedback: S93.412A: Index>Sprain>ankle>calcaneofibular ligament>left>initial encounter S93.432A: Index>Sprain>ankle>tibiofibular ligament>left>initial encounter V00.111A: External cause index>accident>transport>pedestrian>conveyance>roller skates >in-line>fall>initial encounter Y92.480: External cause index>place of occurrence>sidewalk Y93.51: External cause index>activity>roller skating (inline) Y99.8: External cause index>status>leisure activity Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries

Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes You Code It! Application: Application 1: TRUMAN, HERBERT Answer: T46.0X1A, I46.9 Feedback: T46.0X1A: Drug table>digoxin>poisoning, accidental>initial encounter I46.9: Index>Arrest>cardiac Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Application 2: JANKOWSKI, HILDA

Answer: S43.141A, Y92.828, Y93.01, Y99.8 Feedback: S43.141A: Index>Dislocation>acromioclavicular>inferior>right>initial encounter Y92.828: External Causes index>place of occurrence>mountains Y93.01: External Causes index>activity>hiking Y99.8: External Causes index>status>student activity Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Application 3: ZIMMER, CYRUS Answer: S12.110A, S43.015A, V23.49XA, Y92.410, Y93.89, Y99.8 Feedback: S12.110A: Index>Fracture>neck>cervical vertebra>second>dens>anterior>initial encounter S43.015A: Index>Dislocation>humerus, proximal end- redirects us toDislocation>shoulder> humerus>anterior>left>initial encounter V23.49XA: External Causes index>accident>transport>motorcyclist>driver>collision, with>car (traffic)>initial encounter Y92.410: External Causes index>place of occurrence>street or highway>unspecified Y93.89: External Causes index>activity>specified NEC

Y99.8: External Causes index>status>recreational Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Application 4: KIM, LINDA Answer: T23.261A, T20.26XA, T31.0, X10.2XXA, Y92.010, Y93.G3, Y99.8 Feedback: T23.261A: Index>Burn>hand>back~ redirects us to~ Burn>dorsum hand>right>second degree>initial encounter T20.26XA: Index>Burn>face~ redirects us to~ Burn>cheek>second degree>initial encounter T31.0: Index>Burn>extent>less than 10 percent X10.2XXA: External cause index>burn>hot>oil Y92.010: External cause index>place of occurrence>residence>house>kitchen Y93.G3: External cause index>activity>cooking and baking Y99.8: External cause index>status>leisure activity Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07

Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Application 5: O‘MALLEY, REGINA Answer: T49.3X1A, R40.20, Y92.030, Y93.G3, Y99.8 Feedback: T49.3X1A: Drug table>wintergreen oil>poisoning, accidental>initial encounter R40.20: Unconsciousness which sends you to coma>unspecified Y92.030: External cause index>place of occurrence>residence>apartment>kitchen Y93.G3: External cause index>activity>baking Y99.8: External cause index>status>leisure activity Learning Objective: 17.01 Learning Objective: 17.02 Learning Objective: 17.03 Learning Objective: 17.04 Learning Objective: 17.05 Learning Objective: 17.06 Learning Objective: 17.07 Learning Objective: 17.08 Topic: Reporting External Causes of Injuries Topic: Traumatic Injuries Topic: Using Seventh Characters to Report Status of Care Topic: Using the Table of Drugs and Chemicals Topic: Adverse Effects, Poisoning, Underdosing, and Toxic Effects Topic: Reporting Burns Topic: Abuse, Neglect, and Maltreatment Topic: Complications of Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Chapter 18 Coding Genitourinary, Gynecology, Obstetrics, Congenital, and Pediatrics Conditions 2024 Compliant Learning Outcomes

LO 18.1 Identify the details required to accurately report renal and urologic malfunctions. LO 18.2 Explain the conditions affecting the male genital system. LO 18.3 Abstract the components for reporting sexually transmitted diseases accurately. LO 18.4 Enumerate the reasons for gynecologic care. LO 18.5 Apply the guidelines for coding routine obstetrics care. LO 18.6 Determine the correct codes for reporting complications of pregnancy. LO 18.7 Utilize the official guidelines for well-baby encounters and congenital anomalies. Chapter Outline Learning Outcomes Key Terms Renal and Urologic Malfunctions Components of the Urinary System Diagnostic Tools Chronic Kidney Disease CKD with Other Conditions Hypertensive Chronic Kidney Disease Diabetes with Renal Manifestations Anemia in CKD Dialysis Transplantation Acute Renal Failure Urinary Tract Infection Renal Calculi Malignant Neoplasm of the Bladder Diseases of the Male Genital Organs Sexually Transmitted Diseases Bacterial Vaginosis Chlamydia

Genital Herpes Gonorrhea Human Immunodeficiency Virus Human Papillomavirus Pelvic Inflammatory Disease Syphilis Trichomoniasis Gynecologic Care Routine Encounters Endometriosis Uterine Fibroids Pelvic Pain Procreative Management Routine Obstetrics Care Fertilization and Gestation Weeks of Gestation Prenatal Visits Normal Pregnancy High-Risk Pregnancy Incidental Pregnant State Labor and Delivery Normal Delivery Special Circumstances Related to Delivery Outcome of Delivery Pregnancies with Complications Preexisting Conditions Affecting Pregnancy Gestational Conditions Multiple Gestations Fetal Abnormalities Seventh Character Postpartum and Peripartum Conditions Sequelae (Late Effects) of Obstetric Complications Abortive Outcomes Neonates and Congenital Anomalies Neonates Suspected Conditions Not Found Clinically Significant Conditions

Maternal Conditions Affecting the Infant Well-Baby Checks Genetics Genetic Conditions versus Congenital Malformations Inherited Conditions Congenital Malformations Testing Gene Therapy Genetic Disorders Chromosomal Abnormalities Autosomal Recessive Inherited Diseases Multifactorial Abnormalities X-Linked Inherited Diseases Congenital Malformations Chapter Summary Chapter 18 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application Chapter Overview The urinary system is designed to remove the urea from the blood, manufacture urine, and perform waste removal by eliminating the urine. It supports many of the other body systems by ensuring fluid balance and eliminating waste products to avoid toxicity. Understanding the components of this system and their functions will help you correctly interpret the documentation to determine the most accurate code or codes. Some conditions affecting organs in the urinary system are the manifestations of other diseases, such as hypertension or diabetes, whereas others may be the result of an infectious organism. Coders must read carefully (as always) to determine the correct coding process. Females of all ages may go to the gynecologist (GYN) for specialized health care. Sometimes, the physician is referred to as an OB/GYN, an abbreviation for the dual specialization of obstetrics (OB), which focuses on care during pregnancy and the puerperium, and gynecology. The anatomical sites included in the female genital system are the definition of the phrase “private places.” These organs have important functions and are susceptible to disease and injury, as with other body systems. Female anatomy includes many organs and anatomical sites that can be subject to health concerns. Well-woman exams and preventive tests should be annual events in every woman’s life. Each time, a

medical necessity for the visit must be documented. Remember that staying healthy or catching illness or disease early is a medical necessity. Babies are precious and should always be treated with tender loving care. From the moment they are born, babies receive a special version of health care services created especially for them, due to their size and growth patterns. The guidelines for coding the reasons for these services are very specific. Congenital anomalies, whether inherited or caused by an interaction with a chemical, drug, or other environmental factor during gestation, can have a lifelong effect on the child as well as the family. Congenital defects can cause a minor inconvenience, present a challenge, require years of health care treatments, or result in premature death.

Discussion Activities 11. Identify a specific condition or disease that may affect an anatomical site within the urinary system. List the specific signs and symptoms and report the code or codes required for this specific diagnosis. [Learning Outcomes: 18.1] Remind students that when an infection is present, an additional code is often required to specify the pathogen.

12. Many different problems can affect the prostate. Explain the signs and symptoms of at least one of these problems and include the code or codes used to report this diagnosis. Also, explain why a urologist is most often the health care professional to treat the prostate, even though this organ is not part of the urinary system. [Learning Outcome: 18.2] The physical location of the prostate and the fact that it wraps around and feeds semen through the urethra is why a urologist is most often the specialist.

13. Identify one specific disease or reason that would bring a woman to need the care of a gynecologist. Include at least one specific diagnosis and what codes would be reported. [Learning Outcome: 18.4] Remind students that a gynecologist would care for a woman who is not pregnant. Encourage discussions to cover both preventive and diagnostic care.

14. All clinically significant conditions documented by the attending physician should be coded. Coders have six ways to determine this situation. Choose one of the six, explain it in your own words, and include a specific example with diagnosis code. [Learning Outcome: 18.7] A clinically significant condition is one that requires: 1) clinical evaluation; 2) therapeutic treatment; 3) diagnostic procedures; 4) extended length of hospital stay; 5) increased nursing care and/or monitoring; or 6) has implications for future health care needs.

Additional Resources Kidney and Urologic Diseases (National Kidney and Urologic Diseases): http://kidney.niddk.nih.gov/KUDiseases/a-z.aspx Kidneys and Urinary System (MedlinePlus): http://www.nlm.nih.gov/medlineplus/kidneysandurinarysystem.html Prostate Diseases (MedlinePlus): http://www.nlm.nih.gov/medlineplus/prostatediseases.html Urinary Tract Infection (UTI) (Mayo Clinic): http://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/basics/causes/con-20037892

Grey’s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman’s Medical Dictionary: http://www.stedmans.com/ AAPC: http://www.aapc.com American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org American Medical Association: http://www.ama-assn.org

ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm INFECTIOUS DISEASE: COVID-19 When a pregnant woman is admitted to the hospital with a COVID-19 diagnosis, report the principal diagnosis code as O98.51- Other viral diseases complicating pregnancy, [sixth character to identify the specific trimester]. This would be followed by code U07.1 COVID-19. Any other manifestations or co-morbidities should be reported separately. Infections in Newborn: COVIS-As you have learned, when any patient is confirmed to have COVID-19, you need to report code U07.1 COVID-19. In those cases when the documentation confirms that a neonate was infected, either in utero or during the birth process, you will need to report code P35.8 Other congenital viral diseases, followed by U07.1. Of course, if this is documented on the same day as the birth, the principal diagnosis code will still be from code category Z38, then followed by the appropriate viral codes.

Chapter 18 Review Answer Key Let’s Check It! Terminology Part I Answer: 1. K Urinary System 2. L Urinary Tract Infection (UTI) 3. F Genetic Abnormality 4. B Benign Prostatic Hyperplasia (BPH) 5. D Chronic Kidney Disease (CKD) 6. E Deformity 7. G GFR 8. I Prostatitis 9. H Malformation 10. C Bladder Cancer 11. J Urea 12. A Anemic

Learning Objective: 18.01 Learning Objective: 18.02 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part II Answer: 1. D Obstetrics 2. C Gynecologist 3. B Gestation 4. F Puerperium 5. E Prenatal 6. A Abortion Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part III Answer: 1. A Anomaly 2. C Congenital 3. D Low Birth Weight (LBW) 4. E Morbidity 5. G Perinatal 6. H Prematurity 7. B Clinically Significant

8. F Mortality Learning Objective: 18.07 Topic: Neonates and Congenital Anomalies Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: D 5, N18.5 Feedback: GFR below 15 ... CKD stage 5 and would be coded N18.5: Disease>kidney>chronic>stage V Learning Objective: 18.01 Topic: Renal and Urologic Malfunctions Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 2. Answer: C Hydrocele Feedback: Hydrocele is a condition that occurs when fluid collects within the tunica vaginalis of the scrotum, the testis, or the spermatic cord. Learning Objective: 18.02 Topic: Diseases of the Male Genital Organs Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: C A52.03 Feedback: A52.03: Index>Syphilis>endocarditis Learning Objective: 18.03

Topic: Sexually Transmitted Diseases Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 4. Answer: D All of these Feedback: Uterine leiomyoma or uterine fibromyoma, uterine fibroids are tumors located in the female reproductive system. Learning Objective: 18.04 Topic: Gynecologic Care Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: C twice Feedback: G= gravida= how many times this women has been pregnant P= para= how many babies this women has given birth to G2 = this woman has been pregnant twice P2 = this woman has given birth twice Learning Objective: 18.05 Topic: Routine Obstetrics Care Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 6. Answer: A a broken leg Feedback: Z33.1 = Pregnant state, incidental is used when the woman is pregnant, but the current encounter has nothing to do with the pregnancy. Z33.1 will never be a first-listed code. Learning Objective: 18.05 Topic: Routine Obstetrics Care Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: C two codes Feedback: The encounter at which a woman gives birth will have at least two codes: the delivery code and the results of the deliver or the outcome of the delivery code. Learning Objective: 18.05 Topic: Routine Obstetrics Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: D sprained wrist Feedback: Hyperemesis gravidarum, kidney infection, and hemorrhage would be considered complications of pregnancy. Learning Objective: 18.06 Topic: Pregnancies with Complications Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 9. Answer: B birth defect Feedback: A congenital malformation, also known as a birth defect, is a permanent physical defect. Learning Objective: 18.07 Feedback: Neonates and Congenital Anomalies Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1

Level of Difficulty: 1 Easy Est Time: 0-1 minute 10. Answer: D P36.2 Feedback: P36.2: Index>Sepsis>newborn>due to>staphylococcus>aureus Learning Objective: 18.07 Feedback: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Let’s Check It! Guidelines Part I: 1. Answer: severity Feedback: I.C.14.a.1 The ICD-10-CM classifies CKD based on severity. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2.

Answer: stage 1-5 Feedback: I.C.14.a.1 The severity of CKD is designated by stage 1-5. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: 2, mild Feedback: I.C.14.a.1 Stage 2, code N18.2, equates to mild CKD. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: 3, N18.30-N18.32 Feedback: I.C.14.a.1 Stage 3, code N18.30-N18.32, equates to moderate CKD. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: N18.4, severe Feedback: I.C.14.a.1 Stage 4, code N18.4, equates to severe CKD. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications

Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: end-stage-renal disease (ESRD) Feedback: I.C.14.a.1 Code N18.6, End stage renal disease (ESRD), is assigned when the provider has documented end-stage-renal disease (ESRD). Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: N18.6 Feedback: I.C.14.a.1 If both a stage of CKD and ESRD are documented, assign code N18.6 only. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07

Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: chronic kidney disease (CKD), N18, Z94.0 Feedback: I.C.14.a.2 Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the Kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate N18 code for the patient‘s stage of CKD and code Z94.0, Kidney transplant status. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9.

Answer: failure or rejection, I.C.19.g, query Feedback: I.C.14.a.2 If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congen, ital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: CKD, diabetes mellitus and hypertension Feedback: I.C.14.a.3 Patients with CKD may also suffer from other serious conditions, most commonly diabetes mellitus and hypertension. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: sequencing, relationship, based Feedback: I.C.14.a.3 The sequencing of the CKD code in relationship to codes for other contributing conditions is based on the conventions in the Tabular List. See I.C.9. Hypertensive chronic kidney disease. See I.C.19. Chronic kidney disease and kidney transplant complications. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Part II 1. Answer: priority Feedback: I.C.15.a.1 Chapter 15 codes have sequencing priority over codes from other chapters. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04

Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: maternal, never Feedback: I.C.15.a.2 Chapter 15 codes are to be used only on the maternal record, never on the record of the newborn. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: trimester

Feedback: I.C.15.a.3 The majority of codes in Chapter 15 have a final character indicating the trimester of pregnancy. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: ―in childbirth‖ Feedback: I.C.15.a.3 Whenever delivery occurs during the current admission, and there is an ―in childbirth‖ option for the obstetric complication being coded, the ―in childbirth‖ code should be assigned. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: complications, antepartum Feedback: I.C.15.a.4 In instances when a patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the trimester character for the antepartum complication code should be assigned on the basis of the trimester when the complication developed, not the trimester of the discharge. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: ―unspecified trimester‖, insufficient Feedback: I.C.15.a.5 The ―unspecified trimester‖ code should rarely be used, such as when the documentation in the record is insufficient to determine the trimester and it is not possible to obtain clarification. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04

Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: 7th, fetus Feedback: I.C.15.a. 6 Where applicable, a 7th character is to be assigned for certain categories to identify the fetus for which the complication code applies. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: Z34

Feedback: I.C.15.b.1 For routine outpatient prenatal visits when no complications are present, a code from category Z34, Encounter for supervision of normal pregnancy, should be used as the first-listed diagnosis. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: O09 Feedback: I.C.15.b.2 For routine prenatal outpatient visits for patients with high-risk pregnancies, a code from category O09, Supervision of high-risk pregnancy, should be used as the first-listed diagnosis. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: no Feedback: I.C.15.b.3 In episodes when no delivery occurs, the principal diagnosis should correspond to the principal complication of the pregnancy which necessitated the encounter. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: prompted Feedback: I.C.15.b.4 When an obstetric patient is admitted and delivers during that admission, the condition that prompted the admission should be sequenced as the principal diagnosis. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05

Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 12. Answer: Z37, every Feedback: I.C.15.b.5 A code from category Z37, Outcome of delivery, should be included on every maternal record when a delivery has occurred. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Part III:

1. Answer: before, 28th Feedback: I.C.16 For coding and reporting purposes the perinatal period is defined as before birth through the 28th day following birth. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: never Feedback: I.C.16.a.1 Codes in this chapter are never for use on the maternal record. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: newborn Feedback: I.C.16.a.1 Codes from Chapter 15, the obstetric chapter, are never permitted on the newborn record Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: life, condition Feedback: I.C.16.a.1 Chapter 16 codes may be used throughout the life of the patient if the condition is still present. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions

Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: Z38, place, type Feedback: I.C.16.a.2 When coding the birth episode in a newborn record, assign a code from category Z38, Liveborn infants according to place of birth and type of delivery, as the principal diagnosis. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: once Feedback: I.C.16.a.2 A code from category Z38 is assigned only once, to a newborn at the time of birth.

Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: definitive, not Feedback: I.C.16.a.3 Codes for signs and symptoms may be assigned when a definitive diagnosis has not been established. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 1-3 minutes 8. Answer: perinatal, first Feedback: I.C.16.a.3 If the reason for the encounter is a perinatal condition, the code from chapter 16 should be sequenced first. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: originate, continue Feedback: I.C.16.a.4 Should a condition originate in the perinatal period, and continue throughout the life of the patient, the perinatal code should continue to be used regardless of the patient‘s age. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care

Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: default Feedback: I.C.16.a.5 If a newborn has a condition that may be either due to the birth process or community acquired and the documentation does not indicate which it is, the default is due to the birth process and the code from Chapter 16 should be used. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: clinically, should Feedback: I.C.16.a.6 All clinically significant conditions noted on routine newborn examination should be coded. Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03

Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: Chronic kidney disease and kidney transplant status Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate N18 code for the patient‘s stage of CKD and code Z94.0, Kidney transplant status. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider. Feedback: Chronic kidney disease and kidney transplant status Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate N18 code for the patient‘s stage of CKD and code Z94.0, Kidney transplant status. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider. Learning Objective: 18.01 Topic: Renal and Urologic Malfunctions

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: Age, employment status, income level, gender, number of sexual encounters … nothing except taking proper precautions during sex shields someone from getting a sexually transmitted disease (STD). This is true for all types of sexual encounters in which bodily fluids are exchanged—not just intercourse. The paragraphs below present an overview of the STDs considered the most common by the Centers for Disease Control (CDC).

Bacterial Vaginosis Bacterial vaginosis (BV)—the most common vaginal infection in women 16 to 45 years of age, often affecting pregnant women—is caused by an overgrowth of bacteria. Symptoms include odor, itching, burning, pain, and/or a discharge. Code N76.0 Acute vaginitis, would be reported, along with a second code to identify the infectious agent. Chlamydia Caused by a bacterium (Chlamydia trachomatis), chlamydia can result in infertility or other irreversible damage to a woman‘s reproductive organs. The symptoms are mild or absent, so most women don‘t know they have a problem unless their partner is diagnosed. Chlamydia can cause a penile discharge in men. It is the most commonly reported bacterial STD in the United States, according to the CDC. In ICD-10-CM, code A55 Chlamydial lymphogranuloma (venereum), is reported for chlamydia that is transmitted by sexual contact. Note: Do not confuse this with A70 Chlamydia psittaci infections; A74.0 Chlamydial conjunctivitis; A74.81 Chlamydial peritonitis; A74.89, Other chlamydial diseases; or A74.9 Chlamydial infection unspecified, all of which are reported when chlamydia causes another disease. Genital Herpes Genital herpes is caused by one of the herpes simplex viruses: type 1 (HSV-1) or type 2 (HSV-2). In this STD, one or more blisters may appear on or in the genital or rectal area. Once the blister bursts, it can take several weeks for the ulcer to heal. The virus will remain in the body indefinitely, even though no more breakouts may be experienced, because there is no cure. Treatment can reduce the number of outbreaks and diminish the opportunity of transmission to a partner. To code from category A60 Anogenital herpesviral [herpes simplex] infections, you must know the specific anatomical site, such as penis or cervix, to determine the additional characters required. Gonorrhea Gonorrhea, a bacterial STD, can develop in the reproductive organs of men (urethra) and women (cervix, uterus, fallopian tubes, and urethra), in addition to the mouth, throat, eyes, and anus. Symptoms in men include a burning sensation during urination, a penile discharge (white, yellow, or green), and/or

swelling or pain in the testes. Women typically do not experience any symptoms. You will report this diagnosis from ICD-10-CM code category A54 Gonococcal infection, which requires identification of the specific anatomical site of the infection to determine additional characters. Human Immunodeficiency Virus Both types of human immunodeficiency virus (HIV)—HIV-1 and HIV-2—destroy cells within the body that are responsible for helping fight disease (those that are part of the immune system). Soon after the initial infection, some individuals may suffer flu-like symptoms, while others will have no symptoms at all and feel fine. Current medications can help individuals continue to feel well and decrease their ability to transmit the disease. HIV, especially untreated HIV, has known manifestations, including cardiovascular, renal, and liver disease. In the late stages of the disease, when the patient‘s immune system is quite damaged, acquired immune deficiency syndrome (AIDS) may develop. Currently, there is no cure for HIV or AIDS. You will report a confirmed diagnosis of HIV with code B20 HIV, when the patient has, or has had, manifestations or code Z21 when the patient is asymptomatic. Human Papillomavirus There are over 40 different types of human papillomavirus (HPV) that can infect the genital regions, mouth, and/or throat of both men and women. This infection will not cause any signs or symptoms; however, it is known to contribute to the development of genital warts as well as cervical cancer (in women). A connection has also been made between HPV and malignancies in the penis, anus, vulva, vagina, and oropharynx. A patient getting a test to screen for HPV will be reported with code Z11.51 Encounter for screening for human papillomavirus (HPV). Reporting for a female patient with a positive test result will come from R87.8 Other abnormal findings in specimens from female genital organs. Additional characters are required based on the anatomical location (cervix or vagina) and on whether the patient is identified as high-risk or low-risk. Male and female patients would both be reported with a code from R85.8 Other abnormal findings in specimens from digestive organs and abdominal cavity, for HPV-positive results in the anus. A confirmed diagnosis for either a male or female patient would be reported with A63.0 Anogenital (venereal) warts due to (human) papillomavirus (HPV). Pelvic Inflammatory Disease Pelvic inflammatory disease (PID) is often a complication of previous chlamydial, gonococceal, or other STD infection, occurring when the bacterium moves from the vagina into a woman‘s uterus or fallopian tubes. It causes lower abdominal pain. Serious consequences of untreated PID include chronic pelvic pain, formation of abscesses, ectopic pregnancy, and possible infertility. Use code A56.11 Chlamydial female pelvic inflammatory disease, or A54.24 Gonococcal female pelvic inflammatory disease, when sexually transmitted, or use code N73 Other female pelvic inflammatory diseases, or N74 Female pelvic inflammatory disorders in diseases classified elsewhere. Syphilis In its early stages, syphilis, caused by a bacterium (Treponema pallidum), is easy to cure. Signs and symptoms include a rash, particularly on the palmar

and plantar surfaces, as well as a small, round, painless sore on the genitals, anus, or mouth. However, these symptoms mimic many other diseases, often resulting in delayed diagnosis. Code category A50 Congenital syphilis; A51 Early syphilis; A52 Late syphilis; or A53 Other and unspecified syphilis, would be reported when this condition is sexually transmitted. Trichomoniasis Trichomoniasis (trich), a protozoan parasitic (Trichomonas vaginalis) STD, is more common in older women than in men. Most individuals do not know they are infected because only approximately 30% develop any symptoms, such as a genital discharge. While the condition is curable, a person who has trich and goes without treatment increases his or her risk of getting human immunodeficiency virus (HIV). Trich, when present in a pregnant woman, can cause premature delivery of low-birth-weight neonates. Code category A59 Trichomoniasis, requires additional characters to identify the specific anatomical site of the infection. Feedback: Age, employment status, income level, gender, number of sexual encounters … nothing except taking proper precautions during sex shields someone from getting a sexually transmitted disease (STD). This is true for all types of sexual encounters in which bodily fluids are exchanged—not just intercourse. The paragraphs below present an overview of the STDs considered the most common by the Centers for Disease Control (CDC).

Bacterial Vaginosis Bacterial vaginosis (BV)—the most common vaginal infection in women 16 to 45 years of age, often affecting pregnant women—is caused by an overgrowth of bacteria. Symptoms include odor, itching, burning, pain, and/or a discharge. Code N76.0 Acute vaginitis, would be reported, along with a second code to identify the infectious agent. Chlamydia Caused by a bacterium (Chlamydia trachomatis), chlamydia can result in infertility or other irreversible damage to a woman‘s reproductive organs. The symptoms are mild or absent, so most women don‘t know they have a problem unless their partner is diagnosed. Chlamydia can cause a penile discharge in men. It is the most commonly reported bacterial STD in the United States, according to the CDC. In ICD-10-CM, code A55 Chlamydial lymphogranuloma (venereum), is reported for chlamydia that is transmitted by sexual contact. Note: Do not confuse this with A70 Chlamydia psittaci infections; A74.0 Chlamydial conjunctivitis; A74.81 Chlamydial peritonitis; A74.89, Other chlamydial diseases; or A74.9 Chlamydial infection unspecified, all of which are reported when chlamydia causes another disease. Genital Herpes Genital herpes is caused by one of the herpes simplex viruses: type 1 (HSV-1) or type 2 (HSV-2). In this STD, one or more blisters may appear on or in the genital or rectal area. Once the blister bursts, it can take several weeks for the ulcer to heal. The virus will remain in the body indefinitely, even though no more breakouts may be experienced, because there is no cure. Treatment can reduce the number of outbreaks and diminish the opportunity of transmission to a partner. To code from category A60 Anogenital herpesviral [herpes

simplex] infections, you must know the specific anatomical site, such as penis or cervix, to determine the additional characters required. Gonorrhea Gonorrhea, a bacterial STD, can develop in the reproductive organs of men (urethra) and women (cervix, uterus, fallopian tubes, and urethra), in addition to the mouth, throat, eyes, and anus. Symptoms in men include a burning sensation during urination, a penile discharge (white, yellow, or green), and/or swelling or pain in the testes. Women typically do not experience any symptoms. You will report this diagnosis from ICD-10-CM code category A54 Gonococcal infection, which requires identification of the specific anatomical site of the infection to determine additional characters. Human Immunodeficiency Virus Both types of human immunodeficiency virus (HIV)—HIV-1 and HIV-2—destroy cells within the body that are responsible for helping fight disease (those that are part of the immune system). Soon after the initial infection, some individuals may suffer flu-like symptoms, while others will have no symptoms at all and feel fine. Current medications can help individuals continue to feel well and decrease their ability to transmit the disease. HIV, especially untreated HIV, has known manifestations, including cardiovascular, renal, and liver disease. In the late stages of the disease, when the patient‘s immune system is quite damaged, acquired immune deficiency syndrome (AIDS) may develop. Currently, there is no cure for HIV or AIDS. You will report a confirmed diagnosis of HIV with code B20 HIV, when the patient has, or has had, manifestations or code Z21 when the patient is asymptomatic. Human Papillomavirus There are over 40 different types of human papillomavirus (HPV) that can infect the genital regions, mouth, and/or throat of both men and women. This infection will not cause any signs or symptoms; however, it is known to contribute to the development of genital warts as well as cervical cancer (in women). A connection has also been made between HPV and malignancies in the penis, anus, vulva, vagina, and oropharynx. A patient getting a test to screen for HPV will be reported with code Z11.51 Encounter for screening for human papillomavirus (HPV). Reporting for a female patient with a positive test result will come from R87.8 Other abnormal findings in specimens from female genital organs. Additional characters are required based on the anatomical location (cervix or vagina) and on whether the patient is identified as high-risk or low-risk. Male and female patients would both be reported with a code from R85.8 Other abnormal findings in specimens from digestive organs and abdominal cavity, for HPV-positive results in the anus. A confirmed diagnosis for either a male or female patient would be reported with A63.0 Anogenital (venereal) warts due to (human) papillomavirus (HPV). Pelvic Inflammatory Disease Pelvic inflammatory disease (PID) is often a complication of previous chlamydial, gonococceal, or other STD infection, occurring when the bacterium moves from the vagina into a woman‘s uterus or fallopian tubes. It causes lower abdominal pain. Serious consequences of untreated PID include chronic pelvic pain, formation of abscesses, ectopic pregnancy, and possible infertility.

Use code A56.11 Chlamydial female pelvic inflammatory disease, or A54.24 Gonococcal female pelvic inflammatory disease, when sexually transmitted, or use code N73 Other female pelvic inflammatory diseases, or N74 Female pelvic inflammatory disorders in diseases classified elsewhere. Syphilis In its early stages, syphilis, caused by a bacterium (Treponema pallidum), is easy to cure. Signs and symptoms include a rash, particularly on the palmar and plantar surfaces, as well as a small, round, painless sore on the genitals, anus, or mouth. However, these symptoms mimic many other diseases, often resulting in delayed diagnosis. Code category A50 Congenital syphilis; A51 Early syphilis; A52 Late syphilis; or A53 Other and unspecified syphilis, would be reported when this condition is sexually transmitted. Trichomoniasis Trichomoniasis (trich), a protozoan parasitic (Trichomonas vaginalis) STD, is more common in older women than in men. Most individuals do not know they are infected because only approximately 30% develop any symptoms, such as a genital discharge. While the condition is curable, a person who has trich and goes without treatment increases his or her risk of getting human immunodeficiency virus (HIV). Trich, when present in a pregnant woman, can cause premature delivery of low-birth-weight neonates. Code category A59 Trichomoniasis, requires additional characters to identify the specific anatomical site of the infection. Learning Objective: 18.03 Topic: Sexually Transmitted Diseases Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: The very last code directly relating to the baby that is placed on the mother‘s chart is a code from category Z37 Outcome of Delivery. The very first code on the baby‘s chart will be from code category Z38 Live born infants according to place of birth and type of birth. This Z code is used to report a newborn baby has arrived, and is always the principal (first-listed) code. A code from this category can only be used once, for the date of birth. Feedback: The very last code directly relating to the baby that is placed on the mother‘s chart is a code from category Z37 Outcome of Delivery. The very first code on the baby‘s chart will be from code category Z38 Live born infants according to place of birth and type of birth. This Z code is used to report a newborn baby has arrived, and is always the principal (first-listed) code. A code from this category can only be used once, for the date of birth. Learning Objective: 18.05

Topic: Routine Obstetrics Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: The term congenital anomaly means ―abnormality present at birth‖ and therefore refers to any variation from the norm for a neonate. This abnormality may be genetic in nature or a malformation that occurred during gestation. A genetic condition may indicate a chromosomal alteration has been inherited – passed down from parent to child via chromosomal and cell structures. An inherited mutation in the DNA causes a permanent alteration that will affect each and every cell as it multiplies during the maturation of the zygote to embryo to fetus to neonate. There is also a strong probability that this person will pass this along to his or her children. Or, the condition may be a congenital malformation or damage to a chromosome during formation. A congenital malformation, also known as a birth defect, means that something went awry during the gestational process. These alterations can occur spontaneously or be an adverse reaction to a pathogen, drug, radiation, or chemical. Feedback: The term congenital anomaly means ―abnormality present at birth‖ and therefore refers to any variation from the norm for a neonate. This abnormality may be genetic in nature or a malformation that occurred during gestation. A genetic condition may indicate a chromosomal alteration has been inherited – passed down from parent to child via chromosomal and cell structures. An inherited mutation in the DNA causes a permanent alteration that will affect each and every cell as it multiplies during the maturation of the zygote to embryo to fetus to neonate. There is also a strong probability that this person will pass this along to his or her children. Or, the condition may be a congenital malformation or damage to a chromosome during formation. A congenital malformation, also known as a birth defect, means that something went awry during the gestational process. These alterations can occur spontaneously or be an adverse reaction to a pathogen, drug, radiation, or chemical. Learning Objective: 18.07 Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 3-5 minutes 5. Answer: Procreative Management A woman may want to see her doctor regarding her desire to have children now or in the future. Code category Z31 Encounter for procreative management is used only for testing conducted with anticipation of procreation (having children). Code subcategory Z31.6 Encounter for general counseling and advice on procreation, will provide you with a few fifth-character options to include additional details. Perhaps a patient comes in for a test to determine whether or not she is a carrier of a genetic disease before getting pregnant. Most often, such a woman wants to be aware of the possibilities of passing inherited diseases, such as sickle cell anemia or Tay-Sachs, to her baby. The code or codes to report her encounter would be: Z31.430 Encounter of female for testing for genetic diseases carrier status for procreative management and/or Z31.438 Encounter for other genetic testing of female for procreative management Code Z31.5 Encounter for genetic counseling would be used after a genetic test has been done and shown positive results. With good news so far, our female patient may come in next time for fertility testing or, perhaps, a pregnancy test:  Z31.41 Encounter for fertility testing  Z32.00 Encounter for pregnancy test, result unknown  Z32.01 Encounter for pregnancy test, result positive  Z32.02 Encounter for pregnancy test, result negative Feedback: Procreative Management A woman may want to see her doctor regarding her desire to have children now or in the future. Code category Z31 Encounter for procreative management is used only for testing conducted with anticipation of procreation (having children). Code subcategory Z31.6 Encounter for general counseling and advice on procreation, will provide you with a few fifth-character options to include additional details. Perhaps a patient comes in for a test to determine whether or not she is a carrier of a genetic disease before getting pregnant. Most often, such a woman wants to be aware of the possibilities of passing inherited diseases, such as sickle cell anemia or Tay-Sachs, to her baby. The code or codes to report her encounter would be: Z31.430 Encounter of female for testing for genetic diseases carrier status for procreative management and/or

Z31.438 Encounter for other genetic testing of female for procreative management Code Z31.5 Encounter for genetic counseling would be used after a genetic test has been done and shown positive results. With good news so far, our female patient may come in next time for fertility testing or, perhaps, a pregnancy test:  Z31.41 Encounter for fertility testing  Z32.00 Encounter for pregnancy test, result unknown  Z32.01 Encounter for pregnancy test, result positive  Z32.02 Encounter for pregnancy test, result negative Learning Objective: 18.04 Topic: Gynecologic Care Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Basics: 1. Answer: Syndrome, N00.6 Feedback: Acute nephritic syndrome with dense deposit disease: Syndrome, N00.6 N006.6: Index>nephritic, nephritic>acute>with>dense deposit disease Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: Hematuria, N02.5 Feedback: Recurrent hematuria with membranoproliferative glomeruloephritis: Hematuria, N02.5 N02.5: Index>hematuria>idiopathic>with glomerular lesion>membranoproliferative Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: Nephritis, N11.0 Feedback: Chronic interstitial nephritis, reflux associated: Nephritis, N11.0 N11.0: Index>nephritis>tubule-interstotoal>chronic>nonobstructive>refluxassociate Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care

Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4. Answer: Stricture, N13.5 Feedback: Stricture of ureter: Stricture, N13.5 N13.5: Index>stricture>ureter Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 5. Answer: Pregnancy, O00.202 Feedback: Left ovarian ectopic pregnancy: Pregnancy, O00.202 O00.202: Index>pregnancy>ectopic>ovarian>left Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06

Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 6. Answer: Short, O26.873 Feedback: Cervical shortening, third trimester: Short, O26.873 O26.873: Index>short>cervical>third trimester Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 7. Answer: Abortion, O03.9 Feedback: Spontaneous abortion: Abortion, O03.9 O03.9: Index>abortion>spontaneous Learning Objective: 18.01

Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 8. Answer: Embolism, O08.2 Feedback: Embolism following molar pregnancy: Embolism, O08.2 O08.2: Index>embolism>following>ectopic or molar pregnancy Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes

9. Answer: Failure, P28.5 Feedback: Respiratory failure of newborn: Failure, P28.5 P28.5: Index>failure>respiratory>newborn Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 10. Answer: Tachycardia, P29.11 Feedback: Newborn tachycardia: Tachycardia, P29.11 P29.11: Index>tachycardia>newborn Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 11. Answer: Dehydration, P74.1 Feedback: Dehydration of newborn: Dehydration, P74.1 P74.1: Index>dehydration>newborn Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 12. Answer: Jaundice P59.3 Feedback: Neonatal jaundice from breast milk inhibitor: Jaundice P59.3 P59.3: Index>jaundice>newborn>due to or associated with>breast milk inhibitor to conjugation Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases

Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 13. Answer: Mole, O01.0 Feedback: Classic hydatidiform mole: Mole, O01.0 O01.0: Index>mole>hydatidiform>classical Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 14. Answer: Hydrocephalus, Q03.9 Feedback: Hydrocephalus in newborn: Hydrocephalus, Q03.9 Q03.9: Index>hydrocephalus>newborn Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05

Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 15. Answer: Spina bifida, Q05.6 Feedback: Thoracic spina bifida: Spina bifida, Q05.6 Q05.6: Index>spina bifida>thoracic Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes You Code It! Practice: 1. Answer: N03.3

Feedback: N03.3: Index>Syndrome>nephritic redirect us to ~ Nephritis>chronic>with>diffuse>mesangial proliferative glomerulonephritis Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: N20.0 Feedback: N20.0: Index>Calculus>kidney Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: N34.1, B95.62 Feedback: N34.1: Index>Urethritis>non-gonococcal B95.62: Index>Infection>staphylococcus>as cause if disease classified elsewhere>aureus>methicillin resistant Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: N25.1 Feedback: N25.1: Index>Diabetes>insipidus>nephrogenic Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications

Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: N46.023 Feedback: N46.023: Index>Azoospermia>due to>efferent duct obstruction Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: O10.012, Z3A.23 Feedback: O10.012: Index>Hypertension>complicating>pregnancy>preexisting>essential>second trimester Z3A.23: Index>Pregnancy>weeks of gestation>23 Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07

Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: Z32.01 Feedback: Z32.01: Index>Encounter>pregnancy test>results positive Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: O23.12, B96.20, Z3A.25 Feedback: O23.12: Index>Pregnancy>complicated by>infection>bladder>second trimester B96.20: Index>Infection>Escherichia coli>as cause if disease classified elsewhere

Z3A.25: Index>Pregnancy>weeks of gestation>25 Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: O20.9, Z3A.17 Feedback: O20.9: Index>Hemorrhage>antepartum>before 20 weeks gestation Z3A.17: Index>Pregnancy>weeks of gestation>17 Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: O26.21, Z3A.13 Feedback: O26.21: Index>Pregnancy>complicated by>recurrent pregnancy loss>first trimester Z3A.13: Index>Pregnancy>weeks of gestation>13 Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: Z38.00, Q10.2 Feedback: Z38.00: Index>Newborn>born in hospital>vaginal Q10.2: Index>Entropion>congenital Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care

Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: Z38.01, P19.2 Feedback: Z38.01: Index>Newborn>born in hospital>cesarean P19.2: Index>Acidaemia>metabolic>noted at birth Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: Z00.111, Q21.0 Feedback: Z00.111: Index>Newborn>examination>8 to 28 days old Q21.0: Index>Defect>ventricular septal Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04

Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: Z00.110, P28.4, P07.39 Feedback: Z00.110: Index>Newborn>examination>under 8 days old P28.4: Index>Apnea>prematurity P07.39: Index>Pre-term>newborn>gestational age> 36 completed weeks Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15.

Answer: Z38.1, A33 Feedback: Z38.1: Index>Newborn>born outside hospital A33: Index>Tetanus>neonatorum Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application: Application 1: OTTMAN, BELINDA Answer: N18.6, D63.1, Z91.158 Feedback: N18.6: Index>Disease>end stage renal D63.1: Index>Anemia>due to>end stage renal disease Z91.158: Index>Non-compliance>renal dialysis Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care

Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: BANG, PARC Answer: C67.3, Z87.891 Feedback: C67.3: Neoplasm table>bladder>urinary>wall>anterior>malignant, primary Z87.891: Index>History>personal>tobacco dependence Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: VANZELL, LEONORE Answer: N32.81 Feedback: N32.81: Index>Hyperactivity>detrusor muscle Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05

Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: TERRY, MARIANNA Answer: O02.1, Z30.2 Feedback: O02.1: Index>Abortion>missed Z30.2: Index>Encounter>sterilization Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: FAIRBANKS, GREGORY

Answer: Z01.01, P07.39, H35.122 Feedback: Z01.01: Index>Examination>eye>with abnormal findings P07.39: Index>Pre-Term>newborn>gestational age>36 completed weeks H35.122: Index>Retinopathy>of prematurity>stage 1>left Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Answer: Feedback: Learning Objective: 18.01 Learning Objective: 18.02 Learning Objective: 18.03 Learning Objective: 18.04 Learning Objective: 18.05 Learning Objective: 18.06 Learning Objective 18: 07 Topic: Renal and Urologic Malfunctions Topic: Diseases of the Male Genital Organs Topic: Sexually Transmitted Diseases Topic: Gynecologic Care Topic: Routine Obstetrics Care Topic: Pregnancies with Complications Topic: Neonates and Congenital Anomalies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

Chapter 19 Factors Influencing Health Status (Z Codes) 2024 Compliant Learning Outcomes

LO 19.1 Abstract details about preventive services to report their medical necessity. LO 19.2 Determine the medical reasons for early detection testing. LO 19.3 Demonstrate how to report encounters related to genetic susceptibility. LO 19.4 Identify the reasons for observation services to determine the correct code or codes. LO 19.5 Apply the Official Guidelines for reporting aftercare and follow-up care. LO 19.6 Evaluate the specific services provided for organ donation and report the medical necessity. LO 19.7 Distinguish indications of antimicrobial drug resistance to report this accurately. LO 19.8 Employ Z codes accurately.

Chapter Outline Learning Outcomes Key Terms Preventive Care Early Detection Genetic Susceptibility Observation Continuing Care and Aftercare Organ Donation Resistance to Antimicrobial Drugs Z Codes as First-Listed/Principal Diagnosis Chapter Summary Chapter 19 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations

You Code It! Basics You Code It! Practice You Code It! Application Chapter Overview Z codes are codes used to report a reason for a visit to a physician for something other than an illness or injury. As you have learned, there must always be a valid, medical reason for a patient’s encounter with a health care professional. And there are occasions for patients to seek attention even when they are not currently ill. These codes give you the opportunity to explain. As a professional coder, you are responsible to ensure that every physician-patient encounter is supported as medically necessary. You probably know from your own personal experience that there are legitimate reasons for a healthy person to seek the attention of a physician or other health care professional. In ICD-10-CM, virtually all of the codes used to explain these valid reasons are found in the Z code chapter. Here, you will find codes to report the medical necessity for providing preventive care services, performing a screening, observing a patient, and checking for the viability of a potential organ donor. Discussion Activities 15. Explain the difference between a diagnostic test and a screening test. Include an example with its code. [Learning Outcomes: 19.1] This is a great opportunity to discuss preventive care and early detection for better health now and in the future of each student.

16. Genetics testing has enabled us to reduce the instances of certain diseases in our population. Explain the testing available for one type of genetic concern and include the appropriate code. [Learning Outcome: 19.3] Discuss with students the use of counseling codes, such as Z30.0-, Z31.5, Z31.6- and when each type of code may be appropriate.

Additional Resources Preventive Care (HHS.gov): http://www.hhs.gov/healthcare/rights/preventive-care/ Preventive Health Care (MedlinePlus): http://www.nlm.nih.gov/medlineplus/ency/article/001921.htm Preventive Health Services for Adults (HealthCare.gov): https://www.healthcare.gov/preventive-care-benefits/ FAQ about Genetic Testing (National Human Genome Research Institute): http://www.genome.gov/19516567 Genetic Testing (MedlinePlus): http://www.nlm.nih.gov/medlineplus/genetictesting.html

Grey’s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman’s Medical Dictionary: http://www.stedmans.com/ AAPC: http://www.aapc.com

American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org American Medical Association: http://www.ama-assn.org

ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm 2022 updates Social Determinants of Health There are circumstances found in patients’ everyday lives that will directly affect their health and their ability to get healthy and stay healthy. These factors can range from an individual’s education and literacy level to their housing and other economic considerations, and so much more. The path to health equity begins with knowing what these factors are, so we can then, as a society, address them. To this end, these Z code categories have been created, so when the physician or provider has documented these details, we can code/report them. Only then, can the data be analyzed and used to make the healthcare system work with greater consistency. For these purposes, medical coding professionals can collect these details from the physician’s notes as well as patient self-reported influences, and notes from social workers, community healthcare workers, case managers, and nurses, as long as they are documented in the patient’s official medical record.

Social determinants of health codes are located primarily in these ten (10) Z code categories: Z55 Problems related to education and literacy Z56 Problems related to employment and unemployment Z57 Occupational exposure to risk factors Z58 Problems related to physical environment Z59 Problems related to housing and economic circumstances Z60 Problems related to social environment Z62 Problems related to upbringing Z63 Other problems related to primary support group, including family circumstances Z64 Problems related to certain psychosocial circumstances Z65 Problems related to other psychosocial circumstances

Chapter 19 Review Answer Key Let’s Check It! Terminology Answer: 1. E Isogeneic 2. D Carrier 3. A Abnormal Findings 4. I Xenogeneic 5. H Screening 6. G Prosthetic 7. C Autologous 8. F Preventive Care 9. B Allogeneic Leaning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.06 Topic: Preventive Care

Topic: Early Detection Topic: Genetic Susceptibility Topic: Organ Donation Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: A Z00.00 Feeback: Z00.00: Examination>general Learning Objective: 19.02 Topic: Early Detection Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 2. Answer: B Z Feedback: To report the preventive care encounter you will use a Z code to explain the specific reason for the encounter. Learning Objective: 19.01 Topic: Preventive Care Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 3. Answer: C xenogeneic Feedback: A xenogeneic graft is a graft where the donor and recipient are of different species. Learning Objective: 19.06 Topic: Organ Donation Blooms: Understand

CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 4. Answer: A test results that indicate a disease or condition may be present. Feedback: Abnormal findings are test results that indicate a disease or condition may be present. Learning Objective: 19.02 Topic: Early Detection Blooms: Remember CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: D Z46.0 Feedback: Z46.0 is not listed as one of the 20 permitted first-listed or principal diagnosis code. Z46.0 identifies an encounter for fitting and adjustment of spectacles and contact lens. During most encounters, a Z code may be the only code you report, or it may be reported along with others, determined by the specific circumstances. Except for 20 of the Z codes, sequencing is determined by the facts of the encounter and the Official Guidelines, as explained in Sections II and III. The other 20 Z codes are permitted to be only first-listed or principal diagnosis codes: Z00 Encounter for general examination without complaint, suspected or reported diagnosis Z01 Encounter for other special examination without complaint, suspected or reported diagnosis Z02 Encounter for administrative examination Z03 Encounter for medical observation for suspected diseases and conditions ruled out Z04 Encounter for examination and observation for other reasons Z33.2 Encounter for elective termination of pregnancy Z31.81 Encounter for male factor infertility in female patient Z31.82 Encounter for Rh incompatibility status Z31.83 Encounter for assisted reproductive fertility procedure cycle Z31.84 Encounter for fertility preservation procedure Z34 Encounter for supervision of normal pregnancy

Z39 Encounter for maternal postpartum care and examination Z38 Liveborn infants according to place of birth and type of delivery Z42 Encounter for plastic and reconstructive surgery following medical procedure or healed injury Z51.0 Encounter for antineoplastic radiation therapy Z51.1Encounter for antineoplastic chemotherapy and immunotherapy Z52 Donors of organs and tissues Except: Z52.9, Donor of unspecified organ or tissue Z76.1 Encounter for health supervision and care of foundling Z76.2 Encounter for health supervision and care of other healthy infant and child Z99.12 Encounter for respirator [ventilator] dependence during power failure Learning Objective: 19.08 Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: A Z52.3 Feedback: Z52.3: index>donor>bone>marrow Learning Objective: 19.06 Feedback: Organ Donation Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: D Z22.0 Feedback: A carrier is an individual infected with a disease who is not ill but can still pass it to another person; an individual with an abnormal gene that can be passed to a child making the child susceptible to disease. Z22.0: index>carrier>typhoid Learning Objective: 19.03 Feedback: Genetic Susceptibility Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: B Z48.01 Feedback: Z48.01: Aftercare>following surgery>attention to>dressing>surgical Learning Objective: 19.05 Topic: Continuing Care and Aftercare Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: B observation Feedback: If a patient is without signs or symptoms and is being watched for a suspect illness then the patient is under observation. There might be a reason that a physician suspects a patient may be ill despite the absence of signs and symptoms. Code categories Z03 and Z04 enable you to report the reason this was medically necessary. Learning Objective: 19.04 Topic: Observation Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: B Z16.11 Feedback: Z16.11: index>resistance>organism>to>drug> penicillin. Learning Objective: 19.07 Topic: Resistance to Antimicrobial Drugs Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 0-1 minute Let’s Check It! Guidelines: Part I: 1. Answer: Z, any Feedback: I.C.21.a Z codes are for use in any healthcare setting. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: first-listed, depending Feedback: I.C.21.a Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08

Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: not Feedback: I.C.21.b Z codes are not procedure codes. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: procedure Feedback: I.C.21.b

A corresponding procedure code must accompany a Z code to describe any procedure performed. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: secondary Feedback: I.C.21.c.1 Contact/exposure codes may be used as a first-listed code to explain an encounter for testing, or, more commonly, as a secondary code to identify a potential risk. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs

Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: carrier, sequelae Feedback: I.C.21.c.3 Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: past, no, potential Feedback: I.C.21.c.4 Personal history codes explain a patient‘s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03

Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: Family, higher Feedback: I.C.21.c.4 Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: screening, specifically Feedback: I.C.21.c.5 A screening code may be a first-listed code if the reason for the visit is specifically the screening exam. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: present Feedback: I.C.21.c.6 The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected condition are present. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care

Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Part II: 1. Answer: initial, continued Feedback: I.C.21.c.7 Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes

2. Answer: surveillance Feedback: I.C.21.c.8 The follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: multiple Feedback: I.C.21.c.8 A follow-up code may be used to explain multiple visits. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation

Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: Z52, living Feedback: I.C.21.c.9 Codes in category Z52, Donors of organs and tissues, are used for living individuals who are donating blood or other body tissue. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: aftermath, support Feedback: I.C.21.c.10 Counseling Z codes are used when a patient or family member receives assistance in the aftermath of an illness or injury, or when support is required in coping with family or social problems. Learning Objective: 19.01 Learning Objective: 19.02

Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: routine Feedback: I.C.21.c.13 The Z codes allow for the description of encounters for routine examinations, such as, a general check-up, or, examinations for administrative purposes, such as, a pre-employment physical. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: prophylactic, Z40, risk Feedback: I.C.21.c.14 For encounters specifically for prophylactic removal of an organ (such as prophylactic removal of breasts due to a genetic susceptibility to cancer or a family history of cancer), the principal or first-listed code should be a code from category Z40, Encounter for prophylactic surgery, followed by the appropriate codes to identify the associated risk factor (such as genetic susceptibility or family history). Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: The reason for routine and administrative exams is to ensure continued good health by looking for signs of disease as early as detection may be possible, using a physician‘s knowledge and technological advancement. Commonly, these health care encounters are known as annual physicals, well-baby checks,

or well-woman exams. These routine encounters, most often prompted by the calendar rather than the way the patient feels, are reported with Z codes. Feedback: The reason for routine and administrative exams is to ensure continued good health by looking for signs of disease as early as detection may be possible, using a physician‘s knowledge and technological advancement. Commonly, these health care encounters are known as annual physicals, well-baby checks, or well-woman exams. These routine encounters, most often prompted by the calendar rather than the way the patient feels, are reported with Z codes. Learning Objective: 19.02 Topic: Early Detection Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: A patient might be a carrier or suspected carrier of a disease. He or she needs to know so the condition is not unintentionally passed on. Or the patient may have an abnormal gene that may increase a patient‘s chances for developing a disease. This is of particular concern when there is a known family history for conditions that are, or may be, inherited. Tests can be used to confirm, or deny, the presence of an abnormality in a gene that may have been inherited as a prediction of the potential for developing a disease allowing the patient to minimize the risk as much as possible. Feedback: A patient might be a carrier or suspected carrier of a disease. He or she needs to know so the condition is not unintentionally passed on. Or the patient may have an abnormal gene that may increase a patient‘s chances for developing a disease. This is of particular concern when there is a known family history for conditions that are, or may be, inherited. Tests can be used to confirm, or deny, the presence of an abnormality in a gene that may have been inherited as a prediction of the potential for developing a disease allowing the patient to minimize the risk as much as possible. Learning Objective: 19.03 Topic: Genetic Susceptibility Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3.

Answer: A person might require continuous care for a chronic illness which may require long-term use of medication, known as drug therapy. When a patient is taking any type of pharmaceutical on an on-going basis, it is often best when regular monitoring is done to identify potential concerns, such as side effects or loss of potency. The physician-patient relationship to treat a specific illness or injury does not end at the end of a surgical procedure or other type of therapeutic service. A healing illness or injury may require aftercare such as an implanted medical device which may need more frequent encounters to check the device to ensure it is working properly. Feedback: A person might require continuous care for a chronic illness which may require long-term use of medication, known as drug therapy. When a patient is taking any type of pharmaceutical on an on-going basis, it is often best when regular monitoring is done to identify potential concerns, such as side effects or loss of potency. The physician-patient relationship to treat a specific illness or injury does not end at the end of a surgical procedure or other type of therapeutic service. A healing illness or injury may require aftercare such as an implanted medical device which may need more frequent encounters to check the device to ensure it is working properly. Learning Objective: 19.05 Topic: Continuing Care and Aftercare Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: Autologous is the donor tissue is taken from a different site on the same individual's body Allogeneic is the donor and recipient are of the same species (human→human, dog→dog) Xenogeneic is the donor and recipient are of different species Feedback: Autologous is the donor tissue is taken from a different site on the same individual's body Allogeneic is the donor and recipient are of the same species (human→human, dog→dog) Xenogeneic is the donor and recipient are of different species Learning Objective: 19.06 Topic: Organ Donation Blooms: Understand CAAHEP: I.C.1 CAAHEP: IX.C.2 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 2 Medium

Est Time: 3-5 minutes 5. Answer: The 20 Z codes that are only permitted to be first-listed or principal diagnosis codes are: Z00 Encounter for general examination without complaint, suspected or reported diagnosis Z01 Encounter for other special examination without complaint, suspected or reported diagnosis Z02 Encounter for administrative examination Z03 Encounter for medical observation for suspected diseases and conditions ruled out Z04 Encounter for examination and observation for other reasons Z33.2 Encounter for elective termination of pregnancy Z31.81 Encounter for male factor infertility in female patient Z31.82 Encounter for Rh incompatibility status Z31.83 Encounter for assisted reproductive fertility procedure cycle Z31.84 Encounter for fertility preservation procedure Z34 Encounter for supervision of normal pregnancy Z39 Encounter for maternal postpartum care and examination Z38 Liveborn infants according to place of birth and type of delivery Z42 Encounter for plastic and reconstructive surgery following medical procedure or healed injury Z51.0 Encounter for antineoplastic radiation therapy Z51.1- Encounter for antineoplastic chemotherapy and immunotherapy Z52 Donors of organs and tissues Except: Z52.9, Donor of unspecified organ or tissue Z76.1 Encounter for health supervision and care of foundling Z76.2 Encounter for health supervision and care of other healthy infant and child Z99.12 Encounter for respirator [ventilator] dependence during power failure Feedback: The 20 Z codes that are only permitted to be first-listed or principal diagnosis codes are: Z00 Encounter for general examination without complaint, suspected or reported diagnosis Z01 Encounter for other special examination without complaint, suspected or reported diagnosis Z02 Encounter for administrative examination Z03 Encounter for medical observation for suspected diseases and conditions ruled out Z04 Encounter for examination and observation for other reasons Z33.2 Encounter for elective termination of pregnancy

Z31.81 Encounter for male factor infertility in female patient Z31.82 Encounter for Rh incompatibility status Z31.83 Encounter for assisted reproductive fertility procedure cycle Z31.84 Encounter for fertility preservation procedure Z34 Encounter for supervision of normal pregnancy Z39 Encounter for maternal postpartum care and examination Z38 Liveborn infants according to place of birth and type of delivery Z42 Encounter for plastic and reconstructive surgery following medical procedure or healed injury Z51.0 Encounter for antineoplastic radiation therapy Z51.1- Encounter for antineoplastic chemotherapy and immunotherapy Z52 Donors of organs and tissues Except: Z52.9, Donor of unspecified organ or tissue Z76.1 Encounter for health supervision and care of foundling Z76.2 Encounter for health supervision and care of other healthy infant and child Z99.12 Encounter for respirator [ventilator] dependence during power failure Learning Objective: 19.08 Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Basics: 1. Answer: Disability, Z73.6 Feedback: Encounter for disability limiting activities: Disability, Z73.6 Z76.3: index>disability>limiting activities Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation

Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: Screening, Z11.51 Feedback: Encounter for screening form human papillomavirus: Screening, Z11.51 Z11.51: index>screening> human papillomavirus Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: History, Z85.6 Feedback: Personal history of leukemia: History, Z85.6 Z85.6: index>history>personal>leukemia Learning Objective: 19.01

Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4. Answer: Susceptibility, Z15.09 Feedback: Genetic susceptibility to malignant neoplasm: Susceptibility to disease, Z15.09 Z15.09: index>susceptibility>malignant neoplasm Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 5. Answer: Contact, Z20.4 Feedback: Contact with and suspected exposure to rubella: Contact, Z20.4 Z20.4: index>contact (with)>rubella Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 6. Answer: Carrier, Z22.2 Feedback: Carrier of diphtheria: Carrier, Z22.2 Z22.2: index>carrier of>diphtheria Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08

Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 7. Answer: Surveillance, Z30.42 Feedback: Encounter for surveillance of injectable contraceptive: Surveillance, Z30.42 Z30.42: index>prescription of contraceptive>repeat>injectable Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 8. Answer: Management, Z31.9

Feedback: Encounter for procreative management: Management, Z31.9 Z31.9: index>management>procreative Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 9. Answer: Fitting, Z44.31 Feedback: Encounter for fitting and adjustment of external right breast prosthesis: Fitting, Z44.31 Z44.31: index>fitting>device>prosthetic (external) >breast>right Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation

Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 10. Answer: Aftercare, Z47.33 Feedback: Aftercare following explantation of knee joint: Aftercare, Z47.33 Z47.33: index>aftercare>following surgery>explantation of joint prosthesis>knee Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 11. Answer: Donor, Z52.5 Feedback: Cornea donor: Donor, Z52.5 Z52.5: index>donor>cornea Learning Objective: 19.01 Learning Objective: 19.02

Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 12. Answer: High Z72.53 Feedback: High risk bisexual behavior: High Z72.53 Z72.53: index>high>risk>sexual behavior>bisexual Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 13. Answer: Absence, Z89.212 Feedback: Acquired absence of left upper limb below elbow: Absence, Z89.212 Z89.212: index>absence>arm>below elbow>left Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 14. Answer: Examination, Z01.30 Feedback: Encounter for examination of blood pressure without abnormal findings: Examination, Z01.30 Z01.30: index>examination>blood pressure Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08

Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 15. Answer: Presence, Z95.811 Feedback: Presence of heart assist device: Presence, Z95.811 Z95.811: index>presence>heart assist device Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes You Code It! Practice:

1. Answer: Z02.81 Feedback: Z02.81: Examination>medical>paternity testing Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: Z01.20 Feedback: Z01.20: Examination>dental Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: Z01.810 Feedback: Z01.810: Examination>pre-procedural>cardiovascular Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: Z04.2, W86.8XXA, Y92.29, Y93.89, Y99.0 Feedback: Z04.2: Observation>accident>at work W86.8XXA: External cause index>shock>from electric appliance Y92.29: External cause index>place of occurrence>public>building NEC Y93.89: External cause index>activity>specified NEC Y99.0: External cause index>status>civilian activity done for income or pay Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03

Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: Z77.090 Feedback: Z77.090: Exposure>asbestos Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium

Est Time: 3-5 minutes 6. Answer: N39.0, B95.62, Z16.21 Feedback: N39.0: Infection>urinary B95.62: Staphylococcus>as cause of disease classified elsewhere>aureus (MRSA) Z16.21: Resistance>organism>to>drug>vancomycin Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: Z12.73, Z80.41 Feedback: Z12.73: Screening>neoplasm>genitourinary organs>ovary History>family>malignant neoplasm (of) NOS>genital organ>ovary

Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care

Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: Z00.121, D66, Z14.02 Feedback: Z00.121: Examination>child, over 28 days old>with abnormal findings D66: Hemophilia>A Z14.02: Carrier>genetic>hemophilia A>symptomatic Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: Z12.5, Z80.42

Feedback: Z12.5: Screening>neoplasm>prostate Z80.42: History>family>malignant neoplasm>prostate Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: Z34.82 Feedback: Z34.82: Pregnancy>supervision>normal>specified NEC>second trimester Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: Z52.098 Feedback: Z52.098: Donor>blood>specified component>specified donor Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: Z42.1 Feedback: Z42.1: Encounter>breast reconstruction following mastectomy Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08

Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: Z43.3 Feedback: Z43.3: Attention to> colostomy Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: Z51.81, Z79.01, I48.91 Feedback: Z51.81: Encounter>therapeutic drug level monitoring

Z79.01: Therapy>drug>anticoagulant I48.91: Fibrillation>atrial>unspecified Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: Z72.820 Feedback: Z72.820: Deprivation>sleep Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application: Application 1: ELLIOTT, ELLYN Answer: Z02.1 Feedback: Z02.1: Examination>medical>pre-employment Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: GALLOP, MICHAEL Answer: Z38.00, Z00.110, E03.1 Feedback: Z38.00: Newborn>born in hospital Z00.110: Newborn>examination>under 8 days old E03.1: Hypothyroidism>congenital>without goiter Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04

Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: BELLOW, SANDRA Answer: Z31.5, Z31.430 Feedback: Z31.5: Counseling>genetic NEC Z31.430: Screening>genetic>for procreative management~ redirects us ~ Testing>genetic>disease carrier status for procreative management>female Be careful here this is Sandra‘s chart. Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: LESZEK, OGLEV Answer: Z71.51, F12.10 Feedback: Z71.51: Counseling>drug abuser F12.10: Abuse>marihuana~ redirects us ~ Abuse>drug>cannabis>uncomplicated Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05 Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: MONETS, ARNOLD Answer: Z00.01, E83.119 Feedback: Z00.01: Examination>medical>with abnormal findings E83.119: Hemochromatosis>unspecified Learning Objective: 19.01 Learning Objective: 19.02 Learning Objective: 19.03 Learning Objective: 19.04 Learning Objective: 19.05

Learning Objective: 19.06 Learning Objective: 19.07 Learning Objective: 19.08 Topic: Preventive Care Topic: Early Detection Topic: Genetic Susceptibility Topic: Observation Topic: Continuing Care and Aftercare Topic: Organ Donation Topic: Resistance to Antimicrobial Drugs Topic: Z Codes at First-Listed/Principal Diagnosis Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 20 Inpatient (Hospital) Diagnosis Coding 2024 Compliant Learning Outcomes

LO 20.1 Evaluate concurrent and discharge coding methodologies. LO 20.2 Utilize the Official Guidelines specific for inpatient reporting. LO 20.3 Apply the Present-On-Admission (POA) indicators properly. LO 20.4 Determine the impact of diagnosis-related groups (DRGs) on the coding process. LO 20.5 Recognize the importance of the Uniform Hospital Discharge Data Set (UHDDS). Chapter Outline Learning Outcomes Key Terms Concurrent and Discharge Coding Official Coding Guidelines Uncertain Diagnosis Patient Receiving Diagnostic Services Only Present on Admission Indicators General Reporting Guidelines POA Indicators Diagnosis-Related Groups Principal Diagnosis Complications and Co-morbidities

Major Complications and Co-morbidities Uniform Hospital Discharge Data Set Chapter Summary Chapter 20 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Application Chapter Overview Interpreting and reporting the diagnoses for those individuals who have been admitted into an acute care facility, also known as a hospital, has a great deal in common with reporting diagnoses for outpatient facilities. However, there are a few differences. This chapter will review those differences, including the specific changes in guidelines for reporting uncertain diagnoses and assigning present on admission (POA) indicators. Discussion Activities 17. Discuss the factors involved in using DRG to determine reimbursement. [Learning Outcome: 20.4] Students should review consistencies of the standards of care as determined by diagnosis. This is also an excellent opportunity to discuss the determination of principal diagnosis as well as the impact of identifying complications and co-morbidities.

18. Identify the relationship between the reporting of POA indicators and hospital-acquired conditions. [Learning Outcome: 20.3] This discussion can reinforce the connection between the care a hospital provides to a patient and the responsibility this organization should take when a patient suffers an HAC. Include discussion about how, as a manager, one might use training, policies, and procedures to reduce the number of HACs in that facility.

Additional Resources Hospital Compare Quality of Care (CMS): http://www.hospitalcompare.hhs.gov/ The Joint Commission: http://www.jointcommission.org/ Grey‘s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman‘s Medical Dictionary: http://www.stedmans.com/ AAPC: http://www.aapc.com American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org American Medical Association: http://www.ama-assn.org ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm

Chapter 20 Review Answer Key Let’s Check It! Terminology Answer: 1. F Major Complication and Co-morbidity 2. A Co-morbidity 3. H Uniform Hospital Discharge Data Set 4. C Concurrent Coding 5. E Hospital-Acquired Condition (HAC) 6. B Complication 7. D Diagnosis-Related Group (DRG) 8. G Present-On-Admission (POA) Learning Objective: 20.01 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Remember CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: C Discharge summary Feedback: Discharge summary or discharge progress note are signed by the attending physician. Learning Objective: 20.01 Topic: Concurrent and Discharge Coding Blooms: Remember CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2.

Answer: C C50.312, Z80.3 Feedback: The correct code for infiltrating papillary breast carcinoma of the left breast is C503.312. C503.312: Index>neoplasm table>breast>lowerinner>quadrant>malignant, primary. Z80.3: Index>history>family>malignant neoplasm>breast. Learning Objective: 20.02 Topic: Official Coding Guidelines Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 3. Answer: A X Feedback: POA Indicators are as follows: Y: Yes, this conditions was documented by the admitting physician as present at the time of inpatient admission N: No, this condition was not present at the time of inpatient admission. U: Unknown, documentation from the admitting physician is insufficient to determine if condition is present on admission. W: Clinically Undetermined, provider is unable to clinically determine whether condition was present on admission or not. 1: Exempt Learning Objective: 20.03 Topic: Present-On-Admission Indicators Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 4. Answer: B False Feedback: UHDDA is the Uniform Hospital Discharge Data Set which is a compilation of data collected by acute care facilities and other designated health care facilities. Learning Objective: 20.05 Topic: Uniform Hospital Discharge Data Set Blooms: Understand

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 5. Answer: D N Feedback: The POA would be N: No, this condition was not present at the time of inpatient admission. Learning Objective: 20.03 Topic: Present-On-Admission Indicators Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: D postoperative wound infection Feedback: A complication is an unexpected illness or other condition that develops as a result of a procedure, service, or treatment provided during the patient‘s hospital stay. Learning Objective: 20.04 Topic: Diagnosis-Related Groups Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: B False Feedback: Remember that you learned for outpatient coding, that you are not permitted to ever code something identified by the physician in his or her documentation as ―rule out,‖ ―probable,‖ ―possible,‖ ―suspected,‖ or other similar terms of an unconfirmed nature. This guidance (as shown in Section IV, subsection I. Uncertain diagnosis) is different from that provided to inpatient coders. The guidance for inpatient coders is that you are permitted to ―code the condition as if it existed or was established.‖ This is done so that medical necessity can

be reported for tests, observation, or other services and resources used to care for the patient whether or not these efforts resulted in a confirmed diagnosis. Learning Objective: 20.02 Topic: Official Coding Guidelines Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 8. Answer: B credit card number Feedback: The Uniform Hospital Discharge Data Set (UHDDS) is a collection of specific data gathered about hospital patients at discharge. No, this is not an invasion of privacy nor is it a collection of personal data. The information pulled from hospital claim forms are related to demographic and clinical details. Demographic data includes: • Gender • Age • Race and ethnicity • Geographic location • Provider information such as the hospital facility NPI (National Provider Identifier) as well as attending and operating physician(s) • Expected sources of payment including primary and other sources of payment for this care • Length of stay (LOS) determined by date of admission and date of discharge • Total charges billed by the hospital for this admission (this will not include physician and other professional services billed) Clinical data collected evaluates: • Type of admission described as scheduled (planned in advance with preregistration at least 24 hours prior) or unscheduled • Diagnoses including principal and additional diagnoses • Procedures, services, and treatments provided during this admission period • External causes of injury determined by the reporting of external cause codes Learning Objective: 20.05 Topic: Uniform Hospital Discharge Data Set Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 2 Medium Est Time: 0-1 minute 9. Answer: D all of these documentations are important Feedback: Once a patient is discharged, the coder will go through the complete patient record. The most important documentations to look for includes:  Discharge summary or discharge progress notes, signed by the attending physician.  Hospital course, which is a summary of the patient's hospital stay.  Discharge instructions, a copy of which is given to the patient.  Discharge disposition, which contains orders for the patient to be transferred home with special services, transferred to another facility, etc.  The death/discharge summary, which is used if the patient expired prior to discharge. All of these documents should be reviewed to provide you with a complete picture of what procedures, services, and treatments were provided to the patient, along with signs, symptoms, and diagnoses to support medical necessity. Learning Objective: 20.01 Topic: Concurrent and Discharge Coding Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: B acute care facilities Feedback: Hospitals deal with diagnosis and procedure codes as well as diagnosis-related groups (DRG) for Medicare reimbursement, under Medicare Part A—Hospital Insurance. To determine how much an acute care facility will be paid, the Inpatient Prospective Payment System (IPPS) was developed. Within IPPS, each and every patient case is sorted into a DRG. Each DRG has a payment weight assigned to it determined by the typical resources used to care for the patient in that case. This calculation includes the labor costs, such as nurses and technicians, as well as non-labor costs, such as maintenance for equipment and supplies. Learning Objective: 20.04 Topic: Diagnosis-Related Groups Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute Let’s Check It! Guidelines Part I 1. Answer: inpatient Feedback: Section II The circumstances of inpatient admission always govern the selection of principal diagnosis. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: established Feedback: Section II The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as ―that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.‖ Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines

Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: complete, overemphasized Feedback: Section II The importance of consistent, complete documentation in the medical record cannot be overemphasized. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: not, principal Feedback: Section II II.A: Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as principal diagnosis when a related definitive diagnosis has been established. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05

Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: unusual, equally, one Feedback: Section II II.C: In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: discharge, existed Feedback: Section II II.H: If the diagnosis documented at the time of discharge is qualified as ―probable‖, ―suspected‖, ―likely‖, ―questionable‖, ―possible‖, or ―still to be ruled

out‖, or other similar terms indicating uncertainty, code the condition as if it existed or was established. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: admitted, worsens, led Feedback: Section II II.I.1: When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal diagnosis would be the medical condition which led to the hospital admission. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes

8. Answer: diagnostic Feedback: Section III III.A: If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: Abnormal Feedback: Section III III. B: Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: outside, ask Feedback: Section III III.B: If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Part II Instructions: Go to www.cms.gov and click on the Medicare tab in the upper navigation bar. In the left column, select Payment. On the right side select Prospective Payment System. Scroll down to the related links and click on Acute Inpatient PPS. Fill in the blanks accordingly.

1. Answer: inpatient, prospectively Feedback: Section 1886(d) of the Social Security Act (the Act) sets forth a system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set rates. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding

Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: prospective, (IPPS) Feedback: This payment system is referred to as the inpatient prospective payment system (IPPS). Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: diagnosis-related group, average Feedback: Under the IPPS, each case is categorized into a diagnosis-related group (DRG). Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators

Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: divided Feedback: The base payment rate is divided into a labor-related and nonlabor share. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: wage, cost of living Feedback: The labor-related share is adjusted by the wage index applicable to the area where the hospital is located, and if the hospital is located in Alaska or Hawaii, the nonlabor share is adjusted by a cost of living adjustment factor. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups

Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: multiplied Feedback: This base payment rate is multiplied by the DRG relative weight. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: low-income, add-on Feedback: If the hospital treats a high-percentage of low-income patients, it receives a percentage add-on payment applied to the DRG-adjusted base payment rate. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: disproportionate, increase, qualify Feedback: This add-on, known as the disproportionate share hospital (DSH) adjustment provides for a percentage increase in Medicare payment for hospitals that qualify under either of two statutory formulas designed to identify hospitals that serve a disproportionate share of low-income patients. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: approved Feedback: Also if the hospital is an approved teaching hospital it receives a percentage add-on payment for each case paid through IPPS. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: ratio, census Feedback: This add-on known as the indirect medical education (IME) adjustment varies depending on the ratio of residents-to-beds under the IPPS for operating costs, and according to the ratio of residents-to-average daily census under the IPPS for capital costs. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: unusually, outlier Feedback: Finally, for particular cases that are unusually costly, known as outlier cases, the IPPS payment is increased. Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 12. Answer: added Feedback: Any outlier payment due is added to the DRG-adjusted base payment rate, plus any DSH or IME adjustments.

Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: According to CMS Publication 100-04, “Present on admission is defined as present at the time the order for inpatient admission occurs—conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.” Feedback: According to CMS Publication 100-04, “Present on admission is defined as present at the time the order for inpatient admission occurs— conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.” Learning Objective: 20.03 Topic: Present-On-Admission Indicators Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

2. Answer: The Official Coding Guidelines located in your ICD-10-CM book will still provide you guidance. However, there are two instances in which the guidelines direct inpatient coders differently than outpatient.

Uncertain Diagnosis Remember, you learned for outpatient coding that you are not permitted to ever code something identified by the physician in his or her documentation as ―rule out,‖ ―probable,‖ ―possible,‖ ―suspected,‖ or other similar terms of an unconfirmed nature. This guidance (as shown in Section IV, Subsection I, Uncertain diagnosis) is different from that provided to inpatient coders. The guidance for inpatient coders is that you are permitted to ―code the condition as if it existed or was established.‖ This is done so that medical necessity can be reported for tests, observation, or other services and resources used to care for the patient whether or not these efforts resulted in a confirmed diagnosis. Patient Receiving Diagnostic Services Only In the outpatient world, the guidelines instruct you to wait until the test results have been determined and interpreted by the physician as documented in the final report before coding. At that time, confirmed diagnoses, or the signs and symptoms that were documented as the reason for ordering the test, are reported. When you are coding for inpatient services, abnormal test results are not reported unless the physician has documented the clinical significance of those results. Interestingly, in this section of the guidelines, it is reiterated that if the coding professional notices abnormal test results and documentation is unclear from the physician, it is ―appropriate to ask the provider whether the abnormal finding should be added.‖ Feedback: The Official Coding Guidelines located in your ICD-10-CM book will still provide you guidance. However, there are two instances in which the guidelines direct inpatient coders differently than outpatient.

Uncertain Diagnosis Remember, you learned for outpatient coding that you are not permitted to ever code something identified by the physician in his or her documentation as ―rule out,‖ ―probable,‖ ―possible,‖ ―suspected,‖ or other similar terms of an unconfirmed nature. This guidance (as shown in Section IV, Subsection I, Uncertain diagnosis) is different from that provided to inpatient coders. The guidance for inpatient coders is that you are permitted to ―code the condition as if it existed or was established.‖ This is done so that medical necessity can be reported for tests, observation, or other services and resources used to care for the patient whether or not these efforts resulted in a confirmed diagnosis. Patient Receiving Diagnostic Services Only In the outpatient world, the guidelines instruct you to wait until the test results have been determined and interpreted by the physician as documented in the final report before coding. At that time, confirmed diagnoses, or the signs and

symptoms that were documented as the reason for ordering the test, are reported. When you are coding for inpatient services, abnormal test results are not reported unless the physician has documented the clinical significance of those results. Interestingly, in this section of the guidelines, it is reiterated that if the coding professional notices abnormal test results and documentation is unclear from the physician, it is ―appropriate to ask the provider whether the abnormal finding should be added.‖ Learning Objective: 20.02 Topic: Official Coding Guidelines Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: DRG stands for Diagnosis-related groups which is an episodic-care payment system basing reimbursement to hospitals for inpatient services upon standards of care for specific diagnoses grouped by their similar usage of resources for procedures, services, and treatments. Feedback: DRG stands for Diagnosis-related groups which is an episodic-care payment system basing reimbursement to hospitals for inpatient services upon standards of care for specific diagnoses grouped by their similar usage of resources for procedures, services, and treatments. Learning Objective: 20.04 Topic: Diagnosis-Related Groups Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: A co-morbidity is a separate condition or illness present in the same patient at the same time as another unrelated condition or illness. A complication is an unexpected illness or other condition that develops as a result of a procedure, service, or treatment provided during the patient‘s hospital stay. Feedback: A co-morbidity is a separate condition or illness present in the same patient at the same time as another unrelated condition or illness.

A complication is an unexpected illness or other condition that develops as a result of a procedure, service, or treatment provided during the patient‘s hospital stay. Learning Objective: 20.04 Topic: Diagnosis-Related Groups Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: UHDDS stands for Uniform Hospital Discharge Data Set which is a compilation of data collected by acute care facilities and other designated health care facilities. The Uniform Hospital Discharge Data Set (UHDDS) is a collection of specific data gathered about hospital patients at discharge as follows: Demographic data includes: • Gender • Age • Race and ethnicity • Geographic location • Provider information such as the hospital facility NPI (National Provider Identifier) as well as attending and operating physician(s) • Expected sources of payment including primary and other sources of payment for this care • Length of stay (LOS) determined by date of admission and date of discharge • Total charges billed by the hospital for this admission (this will not include physician and other professional services billed) Clinical data collected evaluates: • Type of admission described as scheduled (planned in advance with preregistration at least 24 hours prior) or unscheduled • Diagnoses including principal and additional diagnoses • Procedures, services, and treatments provided during this admission period • External causes of injury determined by the reporting of external cause codes Definitions of these, and other, categories, as determined by the UHDDS are used by ICD-10-CM in the official coding guidelines. Over the years that the UHDDS has been in place, these definitions have been used to assist the reporting of patient data not only in acute care facilities (hospitals), but also for inpatient short-term care, long-term care, and psychiatric hospitals.

Outpatient providers including home health agencies, nursing homes, and rehabilitation facilities also use these definitions for their data. Feedback: UHDDS stands for Uniform Hospital Discharge Data Set which is a compilation of data collected by acute care facilities and other designated health care facilities. The Uniform Hospital Discharge Data Set (UHDDS) is a collection of specific data gathered about hospital patients at discharge as follows: Demographic data includes: • Gender • Age • Race and ethnicity • Geographic location • Provider information such as the hospital facility NPI (National Provider Identifier) as well as attending and operating physician(s) • Expected sources of payment including primary and other sources of payment for this care • Length of stay (LOS) determined by date of admission and date of discharge • Total charges billed by the hospital for this admission (this will not include physician and other professional services billed) Clinical data collected evaluates: • Type of admission described as scheduled (planned in advance with preregistration at least 24 hours prior) or unscheduled • Diagnoses including principal and additional diagnoses • Procedures, services, and treatments provided during this admission period • External causes of injury determined by the reporting of external cause codes Definitions of these, and other, categories, as determined by the UHDDS are used by ICD-10-CM in the official coding guidelines. Over the years that the UHDDS has been in place, these definitions have been used to assist the reporting of patient data not only in acute care facilities (hospitals), but also for inpatient short-term care, long-term care, and psychiatric hospitals. Outpatient providers including home health agencies, nursing homes, and rehabilitation facilities also use these definitions for their data. Learning Objective: 20.05 Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

You Code It! Practice and Application: Application 1: Patient: FALSONE, LEWIS Answer: C50.021, J95.89, Z17.1 Feedback: C50.021: Neoplasm table>breast>areola>malignant, primary>right male breast J95.89: Complication>respiratory system>postoperative>specified NEC Z17.1: Status>estrogen receptor>negative Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: Patient: FRIZZELLI, ALLISON Answer: F25.9, E03.9, E78.00, I10, Z91.19 Feedback: F25.9: Schizoaffective psychosis>unspecified E03.9: Hypothyroidism>unspecified E78.00: Hypercholesterolemia>pure I10: Hypertension Z91.19: Noncompliance>with>medical treatment (hydrochlorothiazide) Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: Patient: TAPPEN, KENNETH Answer: F10.20, F14.20, F33.9, B20, B19.20, I10 Feedback: F10.20: Dependence>alcohol>uncomplicated F14.20: Dependence>drug> cocaine>uncomplicated F33.9: Disorder>depressive>major>recurrent>unspecified B20: Human>immunodeficiency virus (HIV) disease B19.20: Hepatitis>C I10: Hypertension Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: Patient: ENGELS, WARREN Answer: C67.2, D09.0, N30.20 Feedback: C67.2: Neoplasm table>bladder>lateral>malignant, primary D09.0: Neoplasm table>bladder>Ca in situ N30.20: Cystitis>chronic Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04

Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: Patient: BROCKTON, BRIAN Answer: N40.1, I86.8, R31.9 Feedback: N40.1: Enlargement>prostate>with lower urinary tract symptoms I86.8: Varix>specified site NEC R31.9: Hematuria>unspecified Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 6: Patient: LOGAN, PETER Answer: I50.31, I11.0, I35.2, I82.409, I73.00, E03.9, I73.9 Feedback: I50.31 Failure>heart>diastolic>acute [note: exacerbation = acute] I11.0: Hypertension>with>heart failure (congestive) I35.2: Stenosis>aortic>with insufficiency I82.409: Embolism>vein (acute)>deep>unspecified

I73.00: Raynaud‘s syndrome>without gangrene E03.9: Hypothyroidism>unspecified I73.9: Disease>vascular>peripheral>unspecified Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 7: Patient: DRYLER, ARTHUR Answer: G45.9, E78.5, I25.10, N39.0 Feedback: G45.9: Attack>transient ischemic>unspecified E78.5: Hyperlipidemia>unspecified I25.10: Disease>heart>ischemic>atherosclerotic N39.0: Infection>urinary tract>site not specified Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

Application 8: Patient: WESTCOTT, ROSEANNE Answer: R10.9, Z90.89 Feedback: R10.9: Pain>abdominal>unspecified Z90.89: Absence>organ>or site>acquired NEC Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 9: Patient: ROMANSKI, CESAR Answer: F10.20, F15.20, F33.2, B20, A15.7, B18.2, I10 Feedback: F10.20: Dependence>alcohol>uncomplicated F15.20: Dependence>drug>stimulant NEC F33.2: Disorder>depressive>major>recurrent>current episode>severe B20: Human>immunodeficiency virus (HIV) disease A15.7: Tuberculosis>pulmonary>primary B18.2: Hepatitis C>chronic I10: Hypertension Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 10: Patient: MORETTA, TERACIA Answer: Z38.01, Z86.74, P28.81, P36.9, P91.61, K21.9, P92.9 Feedback: Z38.01: Newborn>single>liveborn>born in hospital>delivered by cesarean Z86.74: History>personal>cardiac arrest>resuscitated P28.81: Arrest>respiratory>newborn P36.9: Sepsis>newborn>unspecified P91.61: Encephalopathy>hypoxic ischemic>mild P90: Seizure(s)>newborn K21.9: Reflux>gastroesophageal P92.9: Feeding>problems>newborn>unspecified Learning Objective: 20.01 Learning Objective: 20.02 Learning Objective: 20.03 Learning Objective: 20.04 Learning Objective: 20.05 Topic: Concurrent and Discharge Coding Topic: Official Coding Guidelines Topic: Present-On-Admission Indicators Topic: Diagnosis-Related Groups Topic: Uniform Hospital Discharge Data Set Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 21 Diagnostic Case Studies 2024 Compliant Learning Outcomes

LO 21.1 Apply the techniques learned, carefully read through the case studies, and determine the accurate ICD-10-CM code(s) and the external cause code(s), as required. Chapter Overview

As students worked their way through the last 19 chapters, they have been taught how to abstract documentation and interpret the reasons WHY a physician needed to care for a patient— known as the diagnosis—into ICD-10-CM codes. They also were taught to distinguish signs and symptoms, and other conditions, and when to code those—or not. Now, this chapter provides them with case studies, so they can get some hands-on practice. For each of the following case studies, read through the documentation and: ∙ Determine what code or codes report these reasons, to their most specific level. ∙ Determine how many ICD-10-CM codes they will need to tell the whole story as to WHY the patient required care. ∙ Identify external cause codes in cases of injury or poisoning. ∙ If more than one code is required, determine the sequence in which to report the codes. Remember, the notations, symbols, and Official Guidelines are there to help you get it correct.

Additional Resources Grey’s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman’s Medical Dictionary: http://www.stedmans.com/ AAPC: http://www.aapc.com American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org

American Medical Association: http://www.ama-assn.org ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 21 Answer Key

You Code It! Diagnosis Capstone Case Study 1: JeLysa Hanson Answer: R06.02, R07.89, Y93.71, Y92.017, Y99.8 Feedback: R06.02: Short, shortness>breath R07.89: Pain>chest>musculoskeletal Y93.71: External cause index>activity>boxing Y92.017: External cause index>place of occurrence>residence>house, single family>yard Y99.8: External cause index>status>hobby not done for income Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 3-5 minutes Case Study 2: Harris Teal Answer: J01.11, J45.901 Feedback: J01.11: Sinusitis>acute>frontal>recurrent J45.901: Asthma>allergic extrinsic>with>exacerbation Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study 3: Roger Gill Answer: M71.012, Z87.81 Feedback: M71.012: Abscess>bursa>shoulder>left Z87.81: History>personal>fracture>traumatic Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study 4: Angel Dunbar Answer: E88.42, G40.309 Feedback: E88.42: Syndrome>MERRF G40.309: Epilepsy>generalized>idiopathic>not intractable. Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study 5: Renay Griffith Answer: B55.1 Feedback: B55.1: Leishmaniasis>cutaneous (any type) Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study 6: Marybelle Ostenkowsky Answer: F43.12 Feedback: F43.12: Disorder>stress>post-traumatic stress>chronic Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study 7: Rayonnetta Calhoun Answer: C18.7, E86.0 Feedback: C18.7: Neoplasm table >intestine>large>colon>sigmoid> malignant primary E86.0: Dehydration Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

Case Study 8: Winston Waller Answer: I25.2, N99.0, R57.0, T50.8X5A, F33.0, I10, E11.9 Feedback: I25.2: Infarction>myocardium>healed or old N99.0: Failure>renal>postprocedural R57.0: Shock>cardiogenic T50.8X5A: Table of Drugs and Chemicals>Dye>diagnostic agents> adverse effect> initial encounter F33.0: Disorder>depression>recurrent>current episode>mild I10: Hypertension>essential E11.9: Diabetes>Type 2 Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study 9: Gerald Young Answer: G10 Feedback: G10: Disease>Huntington‘s Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study 10: Marlene Smithson Answer: O98.513, U07.1, Z3A.28 Feedback: O98.513: Pregnancy>complicated by>viral diseases>third trimester U07.1: Disease >COVID-19

Z3A.28: Pregnancy>Weeks of gestation>28 Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes **2021 Official Guideline Chapter 15: b. Selection of OB Principal or First-Listed Diagnosis, paragraph s. COVID019 infection in pregnancy, childbirth, and the puerperium

Case Study 11: Blaize Masters Answer: E10.59, I25.10 Feedback: E10.59: Diabetes>type 1>with>circulatory complications NEC I25.10: Disease>heart>with>ischemic>atherosclerotic Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study 12: Carolina Spencer Answer: Z93.0, J16.8, I26.99, N18.6, E11.9, Z99.2 Feedback: Z93.0: Status>tracheostomy J16.8: Pneumonia>organism> specified NEC I26.99: Embolism>pulmonary N18.6: Disease>end stage renal (ESRD) E11.9: Diabetes>type 2 Z99.2: Status>dialysis (hemodialysis)(peritoneal) Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study 13: Linda Brothers

Answer: O32.1XX0, Z3A.40, Z37.0 Feedback: O32.1Xx0: Delivery>cesarean (for)>breech presentation Z3A.40: Pregnancy>Weeks of gestation>40 37.0: Outcome>single NEC>liveborn Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study 14: Stewart Allen Answer: F31.76, F90.8 Feedback: F31.76: Disorder>bipolar>in remission>in full remission>most recent episode>depressed F90.8: Disorder>attention-deficit hyperactivity>specified type NEC Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study 15: Noah Logan Answer: Q35.5 Feedback: Q35.5: Cleft>palate>hard>with>soft Learning Objective: 21.01 Topic: Diagnostic Case Studies Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

Chapter 22. Introduction to CPT 2024 Compliant

Learning Outcomes LO 22.1 Recognize the main terms for procedure codes. LO 22.2 Distinguish the various sections of CPT and how to use them. LO 22.3 Analyze complete code descriptions. LO 22.4 Recall the meanings of notations and symbols within CPT. LO 22.5 Interpret accurately the Official Guidelines, shown before sections and in-section. LO 22.6 Utilize category II and category III codes, as required.

Chapter Outline Learning Outcomes Key Terms Abstracting for Procedure Coding CPT Coding Book The Organization of the CPT book CPT Resequencing Initiative Understanding Code Descriptions In the Alphabetic Index In the Main Section (Numeric Listing) Unlisted Procedure or Service Notations and Symbols Official Guidelines Section Guidelines In-Section Guidelines Category II and Category III Coding Category II Codes Merit-based Incentive Program System (MIPS) Category III Codes Chapter Summary Chapter 2 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Symbols and Sections Let’s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application

Chapter Overview Emphasize to students that the purpose of coding is to make every effort to ensure clear and concise communication about health care issues among all parties involved. These parties include health care providers, the insurance companies (third-party payers), and government agencies. While students may find it all mysterious at times, coding is simply interpreting health care terms and definitions into numbers or number/letter combinations (alphanumeric codes) that specifically relate to diagnoses and procedures.

Discussion Activities 1. Explain, in your own words, how you will use notations and symbols within CPT to ensure reporting accurate codes. [Learning Outcome: 22.4] 2. Identify a specific procedure, service, or treatment provided by a physician. Explain the specific actions you will take to determine the correct code. Include the specific section or sections you will read through to find the correct code. [Learning Outcome: 22.2]

Additional Resources American Medical Association: www.ama-assn.org American Hospital Association: www.aha.org American Health Information Management Association: www.ahima.org AAPC: http://www.aapc.com ICD-10-CM: http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-and-GEMs.html ICD-10-PCS: http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-PCS-and-GEMs.html )( Duplicate PLA Test [C head] Proprietary laboratory analyses (PLA) tests are represented by U codes, found in the Pathology and Laboratory section of CPT. Occasionally, the same description of a test may be connected by two different codes, and only differentiated by the proprietary name. When this has happened, this symbol )( will appear to the left of the code number, and a notation beneath will identify the matching code. Appendix O will provide additional details to enable you to identify which code you should report. EXAMPLE )( 0143U Drug assay, definitive, 120 or more drugs or metabolites, urine, quantitative liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring (MRM), with drug or metabolite description, comments including sample validation, per date of service (For additional PLA code with identical clinical descriptor, see 0150U. See Appendix O to determine appropriate code assignment)

 Category I PLA [C head] While you will find all of the U codes at the end of the Pathology and Laboratory code section, a majority of these codes do not have Category I status, to be reported as a procedure code. Those U codes which have been accepted by the CPT Editorial Board as a Category I code will have this symbol to its left 

Chapter 22 Review Introduction to CPT Answer Key Let’s Check It! Terminology Answer: 1. G Service 2. F Procedure 3. E Outpatient 4. H Treatments 5. B Category II

6. 7. 8. 9.

A Category I C Category III D Experimental I Unlisted Code

Learning Objective: 22.01 Learning Objective: 22.03 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: Understanding Code Descriptions Topic: Category II and Category III Coding Blooms: Remember CAAHEP: IX.C.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: C Current Procedural Terminology Feedback: CPT stands for Current Procedural Terminology Learning Objective: 22.01 Topic: Abstracting for Procedure Coding Blooms: Remember CAAHEP: IX.C.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: C 6 Feedback: The main body of the CPT book has six sections, presented in numerical order (generally speaking) by code number: o Evaluation and Management: 99201–99499 o Anesthesia: 00100–01999 and 99100–99140 o Surgery: 10022–69990 o Radiology: 70010–79999 o Pathology and Laboratory: 80047–89398 o Medicine: 90281–99199, 99500–99607 You may notice that, while each section within itself is in numerical order (for the most part), the sections are also in numerical order, for the most part. Bottom line . . . read carefully. Learning Objective: 22.02 Topic: CPT Code Book

Blooms: Remember CAAHEP: IX.C.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: B up to the semicolon Feedback: Remember, the rule is to read the part of the code up to the semicolon and then attach the indented description to it. The CPT book does this to save space. Learning Objective: 22.03 Topic: Understanding Code Descriptions Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 4. Answer: B can be found in the front of every CPT section Feedback: The official guidelines you will use to ensure that you are coding procedures correctly are presented right in your CPT. Notice the pages in front of each of the six sections of the main part of the book. The guidelines identify important rules and directives that coders must follow when assigning codes from each section. Learning Objective: 22.05 Topic: Official Guidelines Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 5. Answer: C an add-on code Feedback: The plus symbol (+) identifies an add-on code. Learning Objective: 22.04 Topic: Notations and Symbols Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: D a telemedicine encounter Feedback: The star symbol identifies a telemedicine encounter. Learning Objective: 22.04 Topic: Notations and Symbols Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: A a new code Feedback: The bullet symbol ● identifies a new code, one that is in the CPT book for the first time. Learning Objective: 22.04 Topic: Notations and Symbols Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: C an out-of-numeric-sequence code Feedback: When you see this symbol, a hashtag (#) to the left of a CPT code, this identifies a code that has been added and placed into the code set out of numerical order. Learning Objective: 22.04 Topic: Notations and Symbols Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute

9. Answer: B an accurate Category I code is not available, and an accurate Category III code is not available Feedback: If there aren‘t any accurate Category I codes in the CPT book to report the physician‘s services, you must check the Category III section for an appropriate code before you are permitted to use a Category I unlisted code. The good news is that the CPT book will continue to help you. Category III codes are included in the Alphabetic Index. In addition, there are notations throughout the main sections that will direct you to a Category III code, if applicable. Learning Objective: 22.03 Topic: Understanding Code Descriptions Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: A MIPS Feedback: Beginning in 2017, the Merit-based Incentive Payment System (MIPS) was launched by the Centers for Medicare and Medicaid Services (CMS) to provide a way to reward participating providers with a performance-based payment adjustment to their earned Medicare reimbursements. This program replaces the Physician Quality Reporting System (PQRS) programs.

AMA stands for the American Medical Association RVU stands for Relative Value Units RBRVS stands for Resource-Based Relative Value Scale Learning Objective: 22.06 Topic: Category II and Category III Coding Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute Let’s Check It! Symbols Part I: Answer: 1. F 2. G 3. D

4. H 5. C 6. A 7. E 8. B 9. I 10. J Feedback: 1. F 2. G 3. D 4. H 5. C 6. A 7. E 8. B 9. I 10. J Learning Objective: 22.04 Topic: Notations and Symbols Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Part II: Answer: 1. C 10004–69990 2. E 80047–89398 3. A 99202–99499 4. F 90281–99199, 99500–99607 5. B 00100–01999 and 99100–99140 6. D 70010–79999 Feedback: 1. C 10004–69990 2. E 80047–89398, 0001U-02354U 3. A 99201–99499 4. F 90281–99199, 99500–99607 5. B 00100–01999 and 99100–99140 6. D 70010–79999 Evaluation and Management: 99202–99499 Anesthesia: 00100–01999 and 99100–99140 Surgery: 10004–69990

Radiology: 70010–79999 Pathology and Laboratory: 80047–89398, 0001U-02354U Medicine: 90281–99199, 99500–99607 Learning Objective: 22.02 Topic: CPT Code Book Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Let’s Check It! Rules and Regulations: 1. Answer: Outpatient is a patient who receives services for short term (less than one day) in a physician's office or clinic, without being kept overnight. An Outpatient facility includes: a hospital emergency room, ambulatory care center, same-day surgery center, or walk-in clinic. Feedback: Outpatient is a patient who receives services for short term (less than one day) in a physician's office or clinic, without being kept overnight. An Outpatient facility includes: a hospital emergency room, ambulatory care center, same-day surgery center, or walk-in clinic. Learning Objective: 22.01 Topic: Abstracting for Procedure Coding Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: The American Medical Association (AMA) implemented a new initiative with the 2010 CPT code set. Faced with the challenge of fitting new codes for evolving health care innovation and technology into a preexisting set of numbers, the AMA determined that resequencing codes would be easier for everyone to use rather than starting from scratch and renumbering the entire code set. (That certainly would have caused havoc!) Therefore, when new codes were needed to be added to CPT and there were no more available numbers in the correct sequence, the next available code number was assigned. Different publishers of CPT books present this new information in various ways.

In the AMA-published CPT book, the new code is listed in two places: 1. In its correct numerical sequence. The code is shown in the correct numerical sequence with a notation that informs you where to find the code in its topic-related location. 2. In its correct topic-related location. The code is placed with the other codes that report this procedure or service based on the specific code description. This is highlighted by a symbol to the left of the code number—# (the hashtag sign)—to bring your attention to the fact that this code is not in numerical order. Feedback: The American Medical Association (AMA) implemented a new initiative with the 2010 CPT code set. Faced with the challenge of fitting new codes for evolving health care innovation and technology into a preexisting set of numbers, the AMA determined that resequencing codes would be easier for everyone to use rather than starting from scratch and renumbering the entire code set. (That certainly would have caused havoc!) Therefore, when new codes were needed to be added to CPT and there were no more available numbers in the correct sequence, the next available code number was assigned. Different publishers of CPT books present this new information in various ways. In the AMA-published CPT book, the new code is listed in two places: 1. In its correct numerical sequence. The code is shown in the correct numerical sequence with a notation that informs you where to find the code in its topic-related location. 2. In its correct topic-related location. The code is placed with the other codes that report this procedure or service based on the specific code description. This is highlighted by a symbol to the left of the code number—# (the hashtag sign)—to bring your attention to the fact that this code is not in numerical order. Learning Objective: 22.02 Topic: CPT Code Book Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: On rare occasions, the physician for whom you are coding may perform a service or procedure that does not yet have a designated CPT category I or CPT category III code. When this is the case, you may find it necessary to report an unlisted code. There is one of these codes at the end of almost every section or sub-section.

In these situations, report the unlisted code and attach a special report to the claim that includes the specific details of the procedure or service. Make certain you, as the professional coder, have done everything possible, including querying the physician, to confirm there are no other codes that will sufficiently or accurately report what was done. Feedback: On rare occasions, the physician for whom you are coding may perform a service or procedure that does not yet have a designated CPT category I or CPT category III code. When this is the case, you may find it necessary to report an unlisted code. There is one of these codes at the end of almost every section or sub-section. In these situations, report the unlisted code and attach a special report to the claim that includes the specific details of the procedure or service. Make certain you, as the professional coder, have done everything possible, including querying the physician, to confirm there are no other codes that will sufficiently or accurately report what was done. Learning Objective: 22.03 Topic: Understanding Code Descriptions Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: Some versions of the CPT book may also include a circle with an arrow symbol. This symbol points you toward an AMA-published reference that may be of additional guidance. The notation may direct you toward a particular edition of either the CPT Assistant newsletter or the book CPT Changes: An Insider’s View. The American Medical Association (AMA) describes this subscription only publication, CPT Assistant, as "instrumental to many in their appeal of insurance denials, validating coding to auditors, training their staff and simply making answering day-to-day coding questions second nature." Feedback: Some versions of the CPT book may also include a circle with an arrow symbol. This symbol points you toward an AMA-published reference that may be of additional guidance. The notation may direct you toward a particular edition of either the CPT Assistant newsletter or the book CPT Changes: An Insider’s View. The American Medical Association (AMA) describes this subscription only publication, CPT Assistant, as "instrumental to many in their appeal of insurance denials, validating coding to auditors, training their staff and simply making answering day-to-day coding questions second nature." Learning Objective: 22.04 Topic: Notations and Symbols Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: A CPT category I code is the codes listed in the main text of the CPT book, also known as CPT codes. Category II codes are used for statistical purposes -- to track and measure performance and the quality of care provided in a health care facility. While the number of Category II codes is small, these codes identify specific services that have been proven to be connected to quality patient care. Category II codes have five characters: four numbers followed by the letter F. Category III codes offer the opportunity to collect detailed information on the use of new technological advancements, services, and procedures at their entry point into the practice of health care throughout the United States. Each code identifies an innovative procedure that is at the forefront of the health care industry but not yet widely used or accepted as a standard of care. It is why the codes in this section of the CPT book are considered temporary. Category III codes may eventually become Category I codes (the codes in the main text of the CPT book). New procedures and services are assigned a Category III code so that actual usage can be accurately measured. They are placed in this section of the CPT book and assigned a code that has five characters: four numbers followed by the letter T (for temporary) in the fifth position. Feedback: A CPT category I code is the codes listed in the main text of the CPT book, also known as CPT codes. Category II codes are used for statistical purposes -- to track and measure performance and the quality of care provided in a health care facility. While the number of Category II codes is small, these codes identify specific services that have been proven to be connected to quality patient care. Category II codes have five characters: four numbers followed by the letter F. Category III codes offer the opportunity to collect detailed information on the use of new technological advancements, services, and procedures at their entry point into the practice of health care throughout the United States. Each code identifies an innovative procedure that is at the forefront of the health care industry but not yet widely used or accepted as a standard of care. It is why the codes in this section of the CPT book are considered temporary. Category III codes may eventually become Category I codes (the codes in the main text of the CPT book). New procedures and services are assigned a Category III code so that actual usage can be accurately measured. They are placed in this section of the CPT book and assigned a code that has five characters: four numbers followed by the letter T (for temporary) in the fifth position.

Learning Objective: 22.06 Topic: Category II and Category III Coding Blooms: Analyze CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Basics: 1. Answer: Ligation, 42665 Feedback: Ligation salivary duct, intraoral: Ligation, 42665 42665: index>ligation>salivary duct Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: Manipulation, 25624 Feedback: Carpal scaphoid fracture manipulation: Manipulation, 25624 25624: index>manipulation>carpal scaphoid Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05

Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: Massage, 32160 Feedback: Cardiac Massage: Massage, 32160 32160: index>massage>cardiac Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4. Answer: Meatotomy, 52290 Feedback: Ureter meatotomy: Meatotomy, 52290 52290: index>meatotomy>ureter

Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 5. Answer: Monitoring, 0329T Feedback: Intraocular pressure monitoring for 36 hours: Monitoring, 0329T 0329T: index>monitoring>intraocular pressure Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes

6. Answer: Incision, 26055 Feedback: Tendon sheath incision, finger: Incision, 26055 26055: index>incision>finger>tendon sheath Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 7. Answer: Antigen detection, 87400 Feedback: Immunoassay antigen detection influenza B: Antigen detection, 87400 87400: index>antigen detection>immunoassay>influenza B Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 1 Easy Est Time: 1-3 minutes 8. Answer: Anesthesia, 00120 Feedback: 8Anesthesia for ear biopsy: Anesthesia, 00120 00120: index>anesthesia>biopsy>ear Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 9. Answer: implantable defibrillation, Defibrillator, Heart, Cardiac Assist Devices, 93292 Feedback: Data analysis of implantable defibrillation, wearable device: implantable defibrillation, 93292 93292: index>implantable defibrillation>wearable device>data analysis Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply

CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 10. Answer: keratoplasty, 65710 Feedback: Keratoplasty, anterior lamellar: keratoplasty, 65710 65710: index>leratoplasty>lamellar>anterior Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 11. Answer: X-ray, 73090 Feedback: Lower arm x-ray: X-ray, 73090 73090: index>x-ray>arm, lower Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols

Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 12. Answer: Injection, 50390 Feedback: Kidney cyst injection: Injection, 50390 50390: index>injection>cyst>kidney Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 13. Answer: Cystourethroscopy, 52353 Feedback: Lithotripsy with cystourethroscopy: Cystourethroscopy, 52353 52353: index>cystourethroscopy>lithotripsy Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding

Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 14. Answer: Biopsy, 62269 Feedback: Percutaneous spinal cord biopsy: Biopsy, 62269 62269: index>biopsy>spinal cord>percutaneous Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 15. Answer: education, 4058F Feedback: Pediatric gastroenteritis education, individual: education, 4058F 4058F: index>education services>individual>pediatric gastroenteritis Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04

Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes You Code It! Practice: 1. Answer: 92551 Feedback: 92551: index>audiologic function tests>screening Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 2. Answer: 63075 Feedback: 63075: index>discectomy>cervical Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03

Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 3. Answer: 19100 Feedback: 19100: index>biopsy>breast Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 4. Answer: 76775 Feedback: 76775: Index>ultrasound>retroperitoneal Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04

Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 5. Answer: 32852 Feedback: 32852: index>tansplantation>lung>single, with cardiopulmonary bypass Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 6. Answer: 60240 Feedback: 60240: index>thyroidectomy>total Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04

Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 7. Answer: 29805 Feedback: 29805: index>arthroscopy>diagnostic>shoulder Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 8. Answer: 36555 Feedback: 36555: index>catheter>central venous ~ redirects us ~ Central Venous Catheter Placement>insertion>central>non-tunneled Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04

Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 9. Answer: 24515 Feedback: 24515: index>fracture>humerus>shaft>open treatment Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 10. Answer: 21015 Feedback: 21015: index>resection>radical>tumor>soft tissue>face Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05

Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 11. Answer: 59514 Feedback: 59514: index>cesarean delivery>delivery only Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 12. Answer: 44960 Feedback: 44960: index>appendectomy>appendix excision Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06

Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 13. Answer: 49591 Feedback: 49591: index>hernia repair>spigelian>initial Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 14. Answer: 65205 Feedback: 65205: index>removal>foreign body>eye>external eye Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding

Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 15. Answer: 33210 Feedback: 33210: index>insertion>electrode>heart Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes You Code It! Application: Application 1: MURRAY, CARMEL Answer: 72040 Feedback: 72040: index>x-ray>spine>cervical>3 views Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05

Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: AUSTIN, BRUCE Answer: 68110 Feedback: 68110: index>excision>lesion>conjunctiva>up to 1 cm Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: WOODARD, HOPE Answer: 90845 Feedback: 90845: index>psychoanalysis Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04

Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: JOHNS, CHARLENE Answer: 70486 Feedback: 70486: index>CT scan>without contract>face Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03 Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: PYKE, JOEL Answer: 36620 Feedback: 36620: index>catheterization>arterial system>percutaneous Learning Objective: 22.01 Learning Objective: 22.02 Learning Objective: 22.03

Learning Objective: 22.04 Learning Objective: 22.05 Learning Objective: 22.06 Topic: Abstracting for Procedure Coding Topic: CPT Code Book Topic: Understanding Code Descriptions Topic: Notations and Symbols Topic: Official Guidelines Topic: Category II and Category III Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 23. CPT and HCPCS Level II Modifiers 2024 Complaint Learning Outcomes

LO 23.1 Recognize the purpose of procedure code modifiers. LO 23.2 Apply personnel modifiers per the guidelines. LO 23.3 Correctly use anesthesia physical status modifiers. LO 23.4 Implement ambulatory surgery center modifiers. LO 23.5 Append anatomical site modifiers, as required. LO 23.6 Identify circumstances that require a service-related modifier. LO 23.7 Analyze the guidelines to correctly sequence multiple modifiers. LO 23.8 Determine when a supplemental report is necessary.

Chapter Outline Learning Outcomes Key Terms Modifiers Overview Types of Modifiers Using Modifiers Personnel Modifiers Anesthesia Personnel Modifiers Anesthesia Physical Status Modifiers Ambulatory Surgery Center Hospital Outpatient Use Modifiers Modifier 27 Modifiers 73 and 74 Anatomical Site Modifiers Service-Related Modifiers

Telemedicine Synchronous Services Wound Care Ophthalmology/Optometry ESRD/Dialysis Pharmaceuticals Items/Services Purchase/Rental Items Deceased Patient Claims and Documentation Family Services Treatments/Screenings Transportation Funded Programs Individual/Group Prosthetics Durable Medical Equipment Location Podiatric Care Recording Other Services Medicaid Services Special Rates Sequencing Multiple Modifiers Two or Three Modifiers Needed More than Three Modifiers Needed Sequencing Multiple Modifiers Supplemental Reports Chapter Summary Chapter 23 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Rules and Regulations You Code It! Practice You Code It! Application Chapter Overview Explain to your students that in addition to the code for the specific procedure or service provided to the patient, there may be times when you will need to apply a modifier, and that modifiers are used to present additional information pertinent to a procedure or service that has been given. Demonstrate how these two-character codes add clarification and additional details to the procedure code’s original description, as listed in the main portion of the CPT book. Show how, at times, the modifier provides necessary explanation that directly relates to the reimbursement that the facility or physician will receive. Discussion Activities 1. Choose a modifier and write a scenario that might appear in the physician's notes that would lead you to use that modifier. [Learning Outcome: 23.1] Example 1: Ronald Aswan, a 15-year-old male, came to Dr. Pollard to have corrective surgery on both of his eyes. The modifier used would be -50 to indicate the procedure was done on BOTH eyes—a bilateral procedure. Example 2: John Jung, a 2-week-old male, was rushed into surgery for repair of a septal defect. If the repair is not completed successfully, he may not survive. The correct anesthesia physical status modifier is -P5.

2. Explain the difference between modifier 51 and modifier 59. Give a case scenario that is an example of the proper use for each. [Learning Outcomes: 23.6] Modifier 51 Multiple Procedures: use when more than one procedure or service is provided at the same encounter. Include in this discussion the symbol (and Appendix D) identifying modifier 51 exempt procedure codes (add-on codes). Modifier 59 Distinct Procedural Service: use when additional services that are not normally reported together but provision of these at the same encounter is appropriate in this case.

Additional Resources Modifier 59 Article (CMS): http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org American Health Information Management Association: www.ahima.org AAPC: www.aapc.com Use of CDSS [C head] There are eight (8) modifiers available to explain if the healthcare professional ordering a service, test, medication, or procedure has consulted the Clinical Decision Support System (CDSS) prior to making the decision to document the order. CDSS is an add-on to Electronic Health Records (EHR) systems that enable the professional to access state-ofthe-art evidence-based research at the click of a mouse.

The descriptions of these modifiers report circumstances why the ordering professional may or may not have checked CDSS prior to writing the order. The reasons may include: loss of Internet, access or lack of access to EHR, emergency situations, and there is one modifier to express "unknown". Be sure you do not append the "unknown" modifier as a default. Instead, educate your physician to document these details, so you can append an accurate modifier. Check your HCPCS Level II modifiers: MA, MB, MC, MD, ME, MF, MG, and MH. Chapter 23 Review CPT & HCPCS Level II Modifiers Answer Key Let’s Check It! Terminology Part I Answer: 1. A Alphanumeric 2. D HCPCS Level II Modifier 3. J Supplemental Report 4. I Service-Related Modifier 5. F Nonphysician 6. E Modifier 7. B Ambulatory Surgery Center (ASC) 8. G Personnel Modifier 9. C CPT Code Modifier 10. H Physical Status Modifier Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Supplemental Reports Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part II Answer: 1. B Class A Finding 2. F Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) 3. J Parenteral Enteral Nutrition (PEN) 4. D Class C Finding 5. G End-stage renal disease (ESRD) 6. C Class B Finding 7. I Liters Per Minute (LPM) 8. H Locum Tenens Physician 9. E Clinical Laboratory Improvement Amendment (CLIA) 10. K Urea Reduction Ratio (URR) 11. A Automated Multi-Channel Chemistry (AMCC) Learning Objective: 23.02 Learning Objective: 23.06 Topic: Personnel Modifiers Topic: Service-Related Modifiers Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: Part I: 1. Answer: B an unusual circumstance. Feedback: One of the most important reasons to properly report a procedure code with a modifier is to provide more information about that procedure— additional details that need to be added to the code description to make certain you are completely and accurately reporting what was actually provided to the patient during the encounter. Learning Objective: 23.01 Topic: Modifiers Overview Blooms: Remember CAAHEP: IX.C.1

CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: C procedure codes Feedback: CPT code modifiers are two-digit codes that can be attached to regular CPT codes (procedure codes) from the main portion of the CPT book. Learning Objective: 23.01 Topic: Modifiers Overview Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 3. Answer: D GE Feedback: GE Service performed by a resident without the presence of a teaching physician under the primary care exception Learning Objective: 23.02 Topic: Personnel Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 4. Answer: C anesthesia codes Feedback: Anesthesia physical status modifiers are two-character alphanumeric codes, used only with CPT codes reporting anesthesia services. Learning Objective: 23.03 Topic: Anesthesia Physical Status Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 5. Answer: B LT Feedback: HCPCS Level II modifier is a two-character alphabetic or alphanumeric code that may be appended to a code from the main portion of the CPT book or a code from the HCPCS Level II book. An example of a HCPCS level II modifier would be LT. LT provides additional information that the procedure was performed on the left side. Learning Objective: 23.01 Topic: Modifiers Overview Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: A 81 Feedback: Personnel modifiers is a modifier adding information about the professional(s) attending to the provision of this procedure or treatment to the patient during this encounter. An example of a personnel modifier is -81. Modifier -81 provides the additional information that the service provided by the physician as in a ―minimum assistant surgeon‖ capacity. Learning Objective: 23.02 Topic: Personnel Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: D 99 Feedback: The outpatient claim form, upon which you will record your chosen codes and other information to request reimbursement from the third-party payer, has a limited amount of space in which to place the necessary information, particularly when it comes to the inclusion of modifiers. Some

third-party payers do not permit multiple modifiers to be listed on the same line as the CPT code. Therefore, should your case require three or more modifiers to completely explain all of the circumstances involved, you can use modifier 99. 99 Multiple Modifiers: Under certain circumstances two or more modifiers may be necessary to completely delineate a service. In such situations modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service. Learning Objective: 23.07 Topic: Sequencing Multiple Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: C physical status modifier Feedback: Physical status modifier is a two-character alphanumeric code used to describe the condition of the patient at the time anesthesia services are administered. P5 is an example of a physical status modifier. It provides addition information that the patient‘s health status at the time anesthesia services were provide was ―a moribund patient who is not expected to survive without the operation‖. Learning Objective: 23.03 Topic: Anesthesia Physical Status Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: B the CPT modifier comes first Feedback: When a HCPCS Level II modifier is used in addition to a CPT modifier, the CPT modifier is placed closest to the procedure code, and the HCPCS Level II modifier follows. Learning Objective: 23.07 Topic: Sequencing Multiple Modifiers Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 10. Answer: A supplemental report Feedback: Remember, documentation is your watchword. It is the backbone of the health information management industry. In many situations when a modifier is used, a supplemental report is needed for additional clarification.

Generally, the modifier itself provides a certain amount of explanation; however, the insurance carrier wants more details. You can be efficient and send the specific information along with the claim, or you can wait until the carrier requests additional information. Either way, you will have to supply all the facts. However, if you wait to be asked, you will be delaying payment to your facility. You will need to use your judgement, so as you look at the modifiers you include to tell the whole story, review the codes and modifiers to evaluate if there are any unanswered questions so you can use a supplemental report to answer them. Learning Objective: 23.08 Topic: Supplemental Reports Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part II: 1. Answer: D dressing for seven wounds Feedback: Appending modifier A7 identifies dressing for seven wounds. Learning Objective: 23.06 Topic: Service-Related Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 0-1 minute 2. Answer: B 73 Feedback: Modifiers Approved for Hospital Outpatient Use Level I - Modifier 73 identifies a discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia. Learning Objective: 23.04 Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 3. Answer: D liters per minute Feedback: LPM stands for Liters per minute. Learning Objective: 23.06 Topic: Service-Related Modifiers Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 4. Answer: A 27 Feedback: 27 Multiple Outpatient Hospital E/M Encounters on the Same Date: For hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct E/M encounters performed in multiple outpatient hospital settings on the same date may be reported by adding modifier 27 to each appropriate level outpatient and/ or emergency department E/M code(s). This modifier provides a means of reporting circumstances involving evaluation and management services provided by physician(s) in more than one (multiple) outpatient hospital setting(s) (e.g., hospital emergency department, clinic). Learning Objective: 23.04 Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 5. Answer: C a wheelchair Feedback: An example of a durable medical equipment (DME) is a wheelchair Learning Objective: 23.06 Topic: Service-Related Modifiers Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 6. Answer: B QW Feedback: QW - Clinical Laboratory Improvement Amendment (CLIA) - Federal legislation created for the monitoring and regulation of clinical laboratory procedures Learning Objective: 23.06 Topic: Service-Related Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: A TR Feedback: TR School-based individualized education program (IEP) services provided outside the public school district responsible for the student. Learning Objective: 23.06 Topic: Service-Related Modifiers

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: C E2 Feedback: E2 Lower left eyelid Learning Objective: 23.05 Topic: Anatomical Site Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: B T7 Feedback: T7 Right foot, third digit Learning Objective: 23.05 Topic: Anatomical Site Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 10. Answer: D 53 Feedback: Just a few of the modifiers that might need a supplemental report to ensure complete communications. 22 Increased Procedural Services ... what was it that required the additional time and effort?

23 Unusual Anesthesia ... why was this necessary? 52 Reduced Services ... why couldn't the physician complete the planned procedure in full? 53 Discontinued Procedure ... why did the physician have to stop? Learning Objective: 23.08 Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Let’s Check It! Rules and Regulations: 1. Answer: Comment: (given as feedback) One of the most important reasons to properly report a procedure code with a modifier is to provide more information about that procedure—additional details to the code description to make certain you are completely and accurately reporting the procedure, service, or treatment that was actually provided to the patient during the encounter. Modifiers clarify a report, or claim form, in regard to the following: • A service or procedure had both a professional component and a technical component. • A service or procedure was performed by more than one physician. • A service or procedure was performed in more than one location. • A service or procedure was not performed in total (only part of it was done). • An optional extra service was performed. • A bilateral procedure was performed. • A service or procedure was performed more than once. • Unusual events arose. Feedback: Comment: (given as feedback) One of the most important reasons to properly report a procedure code with a modifier is to provide more information about that procedure—additional details to the code description to make certain you are completely and accurately reporting the procedure, service, or treatment that was actually provided to the patient during the encounter. Modifiers clarify a report, or claim form, in regard to the following: • A service or procedure had both a professional component and a technical component. • A service or procedure was performed by more than one physician. • A service or procedure was performed in more than one location.

• A service or procedure was not performed in total (only part of it was done). • An optional extra service was performed. • A bilateral procedure was performed. • A service or procedure was performed more than once. • Unusual events arose. Learning Objective: 23.01 Topic: Modifiers Overview Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: Anesthesia physical status modifiers are two-character alphanumeric codes: the letter P followed by a number. These modifiers identify the condition of the patient at the time anesthesia services are provided and highlight health circumstances that might dramatically affect the anesthesiologist‘s ability to successfully care for the patient. An explanation of the level of the patient‘s health at the time the anesthesiologist administers the service helps the third-party payer to better understand how hard this physician (anesthesiologist) had to work. Feedback: Anesthesia physical status modifiers are two-character alphanumeric codes: the letter P followed by a number. These modifiers identify the condition of the patient at the time anesthesia services are provided and highlight health circumstances that might dramatically affect the anesthesiologist‘s ability to successfully care for the patient. An explanation of the level of the patient‘s health at the time the anesthesiologist administers the service helps the third-party payer to better understand how hard this physician (anesthesiologist) had to work. Learning Objective: 23.03 Topic: Anesthesia Physical Status Modifiers Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time:3-5 minutes 3. Answer:

The following modifiers, used only with anesthesia codes, are actually HCPCS Level II modifiers. You can see that they provide specific details about the personnel administering the anesthetic to the patient. These details are important for reimbursement as well as responsibility. • AA Anesthesia services that are performed personally by anesthesiologist • AD Medical supervision by a physician: more than four concurrent anesthesia procedures • G8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure • G9 Monitored anesthesia care for patient who has history of severe cardiopulmonary condition • QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals • QS Monitored anesthesia care (MAC) service • QX CRNA service: with medical direction by a physician • QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist • QZ CRNA service without medical direction by a physician Feedback: The following modifiers, used only with anesthesia codes, are actually HCPCS Level II modifiers. You can see that they provide specific details about the personnel administering the anesthetic to the patient. These details are important for reimbursement as well as responsibility. • AA Anesthesia services that are performed personally by anesthesiologist • AD Medical supervision by a physician: more than four concurrent anesthesia procedures • G8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure • G9 Monitored anesthesia care for patient who has history of severe cardiopulmonary condition • QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals • QS Monitored anesthesia care (MAC) service • QX CRNA service: with medical direction by a physician • QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist • QZ CRNA service without medical direction by a physician Learning Objective: 23.02 Topic: Personnel Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time:3-5 minutes

4. Answer: Supplemental report is a letter or report written by the attending physician or other health care professional to provide additional clarification or explanation. In many situations when a modifier is used, a supplemental report is needed for additional clarification. Generally, the modifier itself provides a certain amount of explanation; however, the insurance carrier wants more details. You can be efficient and send the specific information along with the claim, or you can wait until the carrier requests additional information. Either way, you will have to supply all the facts. However, if you wait to be asked, you will be delaying payment to your facility. Feedback: Supplemental report is a letter or report written by the attending physician or other health care professional to provide additional clarification or explanation. In many situations when a modifier is used, a supplemental report is needed for additional clarification. Generally, the modifier itself provides a certain amount of explanation; however, the insurance carrier wants more details. You can be efficient and send the specific information along with the claim, or you can wait until the carrier requests additional information. Either way, you will have to supply all the facts. However, if you wait to be asked, you will be delaying payment to your facility.Learning Objective: 23.08 Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time:3-5 minutes 5. Answer: Class A finding is a nontraumatic amputation of a foot or an integral skeletal portion. Class B finding is an absence of a posterior tibial pulse; absence or decrease of hair growth; thickening of the nail, discoloration of the skin, and/or thinning of the skin texture; and/or absence of a posterior pedal pulse. Class C finding is edema, burning sensation, temperature change (cold feet), abnormal spontaneous sensations in the feet, and/or limping. Feedback: Class A finding is a nontraumatic amputation of a foot or an integral skeletal portion. Class B finding is an absence of a posterior tibial pulse; absence or decrease of hair growth; thickening of the nail, discoloration of the skin, and/or thinning of the skin texture; and/or absence of a posterior pedal pulse. Class C finding is edema, burning sensation, temperature change (cold feet), abnormal spontaneous sensations in the feet, and/or limping.

Learning Objective: 23.06 Topic: Service-Related Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time:3-5 minutes You Code It! Practice: Part I: 1. Answer: -24 Feedback: -24: Unrelated evaluation and management services by the same physician or other qualified health care professional during a postoperative period. Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: -22

Feedback: -22: Increased procedural services: Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: -LT Feedback: -LT: Identifying the left side of the body Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: -74 Feedback: -74: Identify the discontinued procedure by appending modifier 74Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: -57 Feedback: -57: Decision for Surgery Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview

Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 6. Answer: -F3 Feedback: -F3: Left hand, fourth digit Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 7. Answer: -P5

Feedback: -P5: A moribund patient who is not expected to survive without the operation Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 8. Answer: -82 Feedback: -82: Assistant Surgeon (when qualified resident surgeon not available) Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 9. Answer: -32 Feedback: -32: Mandated Services Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 10. Answer: -63 Feedback: -63: Procedure Performed on Infants less than 4 kg Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07

Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 11. Answer: -T5 Feedback: -T5: Right foot, great toe Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 12.

Answer: -52 Feedback: -52: Reduced Services Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 13. Answer: -LC Feedback: -LC: Left circumflex coronary artery Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply

CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 14. Answer: -50 Feedback: -50: Bilateral Procedure Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 15. Answer: -26 Feedback: -26: Professional Component Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08

Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Part II: 1. Answer: E1 Feedback: 1. E1 - Upper left eyelid Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

2. Answer: SB Feedback: SB - Nurse Midwife. Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: GW Feedback: GW - Service not related to the hospice patient‘s terminal condition. Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: GM Feedback: GM - Multiple patients on one ambulance trip. Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: H9 Feedback: H9 - Court ordered. Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07

Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 6. Answer: G9 Feedback: G9 - Monitored anesthesia care for patient who has history service cardiopulmonary condition. Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

7. Answer: A3, TD Feedback: A3, TD – A3=Dressing for three wounds. TD=RN Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 8. Answer: G6 Feedback: G6 - ESRD patient for whom less than six dialysis sessions have been provided in a month. Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers

Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 9. Answer: CC Feedback: CC - Procedure code change (used to indicate that a procedure code previously submitted was changed either for an administrative reason or because an incorrect code was filed). Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 10. Answer: BP Feedback: BP - The beneficiary has been informed of the purchase and rental options and has elected to purchase the item. Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03

Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 11. Answer: F5 Feedback: F5 - Right hand, thumb. Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 3-5 minutes 12. Answer: SK Feedback: SK - Member of high risk population (use only with codes for immunization). Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 13. Answer: U3 Feedback: U3 - Medicaid Level of care 3, as defined by each state. Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers

Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 14. Answer: SW Feedback: SW - Services provided by a certified diabetic educator. Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 15. Answer: SF Feedback: SF - Second opinion ordered by a professional review organization (PRO) per Section 9401, P.L. 99-272 (100%-reimbursement-no Medicare deductible or co-insurance). Learning Objective: 23.01

Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Application Application 1: RISHER, BELVA Answer: 45384, 45380-59 Feedback: 45384: Index>colonoscopy>proximal to splenic flexure>with destruction>lesion 45380-59: Index>colonoscopy>proximal to splenic flexure>with biopsy>-59 Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers

Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: GILMORE, STEVEN Answer: 45330-53 Feedback: 45330-53: Index>sigmoidoscopy>diagnostic>discontinued Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: SCHERINI, STEPHANIE Answer:

32852-66, 00580-P5 Feedback: 32852-66: Index>transplantation>lung>single, with cardiopulmonary bypass> surgical team 00580-P5: Index>anesthesia>lung>transplant>P5 Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: WILBORN, AMANDA Answer: 92352-LT-VP Feedback: 92352-LT-VP: CPT index>Fitting>Spectacle Prosthesis>aphakia>monofocal LT: Left VP: Aphakic patient Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview

Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: HOLDER, ANDREW Answer: 70450-26 Feedback: 70450-26: CT scan>without contrast>brain>professional component Learning Objective: 23.01 Learning Objective: 23.02 Learning Objective: 23.03 Learning Objective: 23.04 Learning Objective: 23.05 Learning Objective: 23.06 Learning Objective: 23.07 Learning Objective: 23.08 Topic: Modifiers Overview Topic: Personnel Modifiers Topic: Anesthesia Physical Status Modifiers Topic: Ambulatory Surgery Center Hospital Outpatient Use Modifiers Topic: Anatomical Site Modifiers Topic: Service-Related Modifiers Topic: Sequencing Multiple Modifiers Topic: Supplemental Reports Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 3-5 minutes Chapter 24. CPT Evaluation and Management Codes 2024 Compliant Learning Outcomes

LO 24.1 Explain the purpose of E/M codes. LO 24.2 Abstract the details for determining the location of the encounter. LO 24.3 Interpret the relationship between physician and patient. LO 24.4 Analyze the documentation to accurately determine the type of E/M service provided. LO 24.5 Ascertain the correct code for preventive care (annual physicals). LO 24.6 Cull the appropriate information from the documentation related to E/M services. LO 24.7 Apply the rules of the Global Surgical Package. LO 24.8 Assign E/M modifiers and add-on codes accurately. LO 24.9 Determine the most accurate way to report special evaluation services. LO 24.10 Validate and report the provision of coordination and management services.

Chapter Outline Learning Outcomes Key Terms What Are E/M Codes? Face-to-Face (Office and Other Outpatient Visits) Unit/Floor Time (Hospital and Other Inpatient Visits) Locations Where the E/M Services Were Provided Location-Specific Headings in the E/M Section Relationship between Provider and Patient New or Established Patient New Patient Established Patient Initial or Subsequent Care Consultations Referral or Consultation? Types of E/M Services Level of Service Level of Patient History Level of Physical Examination Level of Medical Decision Making Combining Multiple Levels into One E/M Code Critical Care and Intensive Care Services Counseling and/or Risk Factor Reduction Intervention Long-Term Care Services Care Plan Oversight Services Admission to a Nursing Facility Subsequent Nursing Facility Care Case Management Services Newborn and Pediatric E/M Care

Home Services Non-Face-to-Face Preventive Medicine Services Abstracting the Physician’s Notes E/M in the Global Surgical Package E/M Modifiers and Add-On Codes Prolonged Services: 99354–99359 Special Evaluation Services Coordination and Management Services Complex Chronic Care Coordination Services Transitional Care Management Services Chapter Summary Chapter 24 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application

Chapter Overview Explain how Evaluation and Management (E/M) is the first section in the CPT book and lists codes numbered 99202 to 99499. Show how these codes are used to report, and reimburse for, physician services that focus on the expertise and thought process provided to a patient. Outline for the students that this includes:  Talking with the patient and his or her family,  Reviewing data such as test and examination results,  Consulting with other health care professionals. Emphasize that all of these elements, including all of the training and education that this health care professional has had, go into the decision of what to do next for the patient—what advice, what prescription, what treatment, what procedure. E/M codes provide a way to reimburse this health care professional for this assessment and supervision of the patient’s care. Discussion Activities 1. In your own words, explain specifically what kinds of services are reported by evaluation and management codes. For what exactly do they reimburse? [Learning Outcomes: 24.1] Discuss the importance of the expertise of the healthcare provider time in the exam room talking with the patient, asking questions, determining a diagnosis and proper course of treatment. 2.

Many times, a physician refers a patient to a specialist for a second opinion. Sometimes it is the patient or family that desires a second opinion. Explain the proper way to code and report these services [Learning Outcome: 24.3] Remind students to read the in-section guidelines for reporting a consultation, and that whether another physician or health care professional requests the consultation makes a difference for which subsection of codes are used.

Additional Resources American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org American Health Information Management Association: www.ahima.org AAPC: www.aapc.com

Chapter 24 Review CPT Evaluation & Management Section Answer Key Let’s Check It! Terminology Part I

Answer: 1. K Relationship 2. A Consultation 3. F Level of Physical Examination 4. D History of Present Illness 5. G Medical Decision Making (MDM) 6. E Level of Patient History 7. I PFSH 8. B Established Patient 9. H New Patient 10. C Evaluation and Management (E/M) 11. J Problem-Pertinent System Review Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part II: Answer: 1. F Global Surgical Package 2. K Risk Factor Reduction Intervention 3. G Hospice 4. B Basic Personal Services 5. J Preventive 6. I Nursing facility 7. H Interval 8. D Critical Care Services 9. E ESRD 10. C Care Plan Oversight Services 11. A Anticipatory Guidance 12. L Transfer of Care Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05

Learning Objective: 24.07 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: E/M in the Global Surgical Package Topic: Coordination and Management Services Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: Part I: 1. Answer: B taking continuing education classes Feedback: E/M codes are used to report and reimburse physicians for their expertise and thought processes involved in diagnosing and treating patients, such as • Talking with the patient and his or her family. • Reviewing data such as complaints, signs, symptoms, and examination results. • Doing research in medical books and journals. • Consulting with other health care professionals. Learning Objective: 24.01 Topic: What Are E/M Codes? Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 2. Answer: A where the patient met with the physician Feedback: The first element you must identify is the location of the encounter between the health care professional (physician) and the patient. Learning Objective: 24.02

Topic: Location Where the E/M Services Were Provided Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 3. Answer: D a new patient Feedback: A new patient is a person who has not received any professional services within the past 3 years from either the provider or another provider of the same specialty and the same subspecialty who belongs to the same group practice. Learning Objective: 24.03 Topic: Relationship between Provider and Patient Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 4. Answer: C referral; Feedback: A referral is when one physician transfers the care and treatment for a patient to another physician.

Learning Objective: 24.04 Topic: Types of E/M Services Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 5. Answer: D Level of History and Level of Physical Examination Feedback: Physicians need to document the patient's history and observations noted during a physical examination for continuity of care. These are the key details health care professionals track over time to support early diagnoses and predictive indictors. Learning Objective: 24.04 Topic: Types of E/M Services Blooms: Understand

CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 6. Answer: A Medical Decision Making Feedback: The level of medical decision making (MDM) provided by the physician during the encounter is the determining factor when identifying the appropriate E/M code. Learning Objective: 24.04

Topic: Types of E/M Services Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute

7. Answer: C self-limited or minor problem Feedback: According to the E/M section guidelines Number and Complexity of Problems Addressed at the Encounter A self-limited or minor problem is a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status. Learning Objective: 24.04 Topic: Types of E/M Services Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 8. Answer: C Travel Feedback: Physician or other qualified health care professional time includes the following activities, when performed:      

preparing to see the patient (eg, review of tests) obtaining and/or reviewing separately obtained history performing a medically appropriate examination and/ or evaluation counseling and educating the patient/family/caregiver ordering medications, tests, or procedures referring and communicating with other health care professionals (when not separately reported)

 

documenting clinical information in the electronic or other health record independently interpreting results (not separately reported) and communicating results to the patient/ family/caregiver  care coordination (not separately reported) Do not count time spent on the following: Do not count time spent on the following: the performance of other services that are reported separately  travel  teaching that is general and not limited to discussion that is required for the management of a specific patient

Learning Objective: 24.04 Topic: Types of E/M Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: C temporary Feedback: A consultation is an encounter for purposes of a second physician‘s opinion or advice, requested by another physician, o appropriate sources (i.e. non-physician practitioner: CRNP:NP, PA‘s etc.) regarding the management of a patient‘s specific health concern. A consultation is planned to be a short-term relationship between a health care professional and a patient. Learning Objective: 24.03 Topic: Relationship between Provider and Patient Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: A Office Visit and initial Hospital Care. Feedback: When the patient is admitted to the hospital as an impatient or to observation status during an encounter in another site of service (e.g., hospital emergency department, office, nursing facility), the services in the initial site may be separately reported. Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same.

Learning Objective: 24.03 Topic: Relationship between Provider and Patient Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Part II: 1. Answer: B admission into the hospital. Feedback: Preventive medical E/M encounter may include the following services • Counseling. • Anticipatory guidance. • Risk factor reduction interventions. Learning Objective: 24.05 Topic: Preventive Medicine Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 2. Answer: D a separate E/M code appended with modifier 25. Feedback: If during the course of the preventive medicine examination, the physician finds something of concern that warrants special and extra attention involving the key components of a problem-oriented E/M service, the extra work should be coded with a separate E/M code appended with modifier 25. It is applicable only when the same physician does the extra service on the same date. Learning Objective: 24.08 Topic: E/M Modifiers and Add-On Codes Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 3. Answer: B 15-30. Feedback: Prolonged service codes report E/M services that are at least 15-30 minutes longer than the amount of time represented by standard E/M codes.

Learning Objective: 24.04 Topic: Types of E/M Services

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 4. Answer: B a hospital discharge code and an admission to the nursing facility code. Feedback: If the patient has been discharged from inpatient status on the same day as being admitted to a nursing facility, you code the physician‘s discharge services separately from the admission. Learning Objective: 24.04 Topic: Types of E/M Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 5. Answer: C 99377-99378 range. Feedback: Care plan oversight services provided for a patient in a hospice setting are coded from the 99377–99378 range. Learning Objective: 24.04 Topic: Types of E/M Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: B both an office visit code and an admission to nursing facility code. Feedback: When the patient is admitted to the nursing facility in the course of an encounter in another site of service (e.g., hospital emergency department, office), the services in the initial site may be separately reported. Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same.

Learning Objective: 24.04 Topic: Types of E/M Services Blooms: Apply

CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: B 99478-99479 range. Feedback: Code range 99478-99479 identifies subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant. Learning Objective: 24.04 Topic: Types of E/M Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: A length of time. Feedback: The codes you choose to report critical care services are determined by the services provided for the critically ill or injured patient, and the total length of unit/floor time of the encounter. Learning Objective: 24.04 Topic: Types of E/M Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: C coded from 99366-99368. Feedback: Code range 99366-99368 identifies medical team conference, with direct contact with patient and/or family and medical team conference, without direct patient and/or family. Learning Objective: 24.04 Topic: Types of E/M Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 10. Answer: A explains an unusual circumstance. Feedback: Modifiers may be used in conjunction with an E/M code to provide additional information about an encounter. Each modifier specifically explains an unusual circumstance that may justify the payment to the provider and avoid having to appeal a denied claim later on. Learning Objective: 24.08 Topic: E/M Modifiers and Add-On Codes Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let's Check It! Guidelines 1. Answer: face-to-face Feedback: Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s). Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package

Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: exact, subspecialty Feedback: An established patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3.

Answer: chief complaint Feedback: A chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient‘s words. Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: Concurrent care Feedback: Concurrent care is the provision of similar services (eg, hospital visits) to the same patient by more than one physician or other qualified health care professional on the same day. Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08

Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: not Feedback: Levels of E/M services are not interchangeable among the different categories or subcategories of service. Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: five Feedback: The E/M codes recognize five types of presenting problems. Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: emergency department Feedback: Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time. Therefore, it is often difficult to provide accurate estimates of the time spent face-to-face with the patient. Learning Objective: 24.01

Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: office, outpatient, hospital, inpatient Feedback: Intraservice times are defined as face-to-face time for office and other outpatient visits and as unit/floor time for hospital and other inpatient visits. Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services

Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: history Feedback: The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s). CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: examination Feedback: The extent of the examination performed is dependent on clinical judgment and on the nature of the presenting problem(s). Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package

Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: Medical decision making Feedback: Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option. Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 12. Answer: counseling, coordination, time Feedback:

When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M services. Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: The location-specific heading in the E/M section are as follows: • Office or Other Outpatient Services • Hospital Observation Services • Hospital Inpatient Services • Office or Other Outpatient Consultations • Inpatient Consultations • Emergency Department Services • Nursing Facility Services • Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services

• Domiciliary, Rest Home (e.g., Assisted Living Facility), or Home Care Plan Oversight Services • Home Services Feedback: The location-specific heading in the E/M section are as follows: • Office or Other Outpatient Services • Hospital Observation Services • Hospital Inpatient Services • Office or Other Outpatient Consultations • Inpatient Consultations • Emergency Department Services • Nursing Facility Services • Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services • Domiciliary, Rest Home (e.g., Assisted Living Facility), or Home Care Plan Oversight Services • Home Services Learning Objective: 24.02 Topic: Location Where the E/M Services Were Provided Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Special Evaluation Services Answer: In cases when a patient is about to have a life insurance or disability certificate issued, the insurer often requires the attending physician to provide an evaluation to establish a baseline of data. The visit does not involve any actual treatment or management of the patient‘s condition—it accounts for the time to create the appropriate documentation. The codes in range 99450–99456 apply to both new and established patients. The three codes within this subsection are very specific as to which services are included: 99450 Basic life and/or disability examination that includes:  Measurement of height, weight, and blood pressure;  Completion of a medical history following a life insurance pro forma;  Collection of blood sample and/or urinalysis complying with ―chain of custody‖ protocols; and  Completion of necessary documentation/certificates 99455 Work related or medical disability examination by the treating physician that includes: • Completion of a medical history commensurate with the patient‘s condition; • Performance of an examination commensurate with the patient‘s condition; • Formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; • Development of future medical treatment plan; and • Completion of necessary documentation/certificate and report.

99456 Work related or medical disability examination by other than the treating physician that includes: • Completion of a medical history commensurate with the patient‘s condition; • Performance of an examination commensurate with the patient‘s condition; • Formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; • Development of future medical treatment plan; and • Completion of necessary documentation/certificate and report. Be aware of the notation beneath code 99456: (Do not report 99455, 99456 in conjunction with 99080 for the completion of Workman‘s Compensation forms) 99080 Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form.

Learning Objective: 24.09 Topic: Types of E/M Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

3. Answer: Anticipatory guidance is the physician‘s offering suggestions for behavior modification or other preventive measures related to a patient‘s high risk for a condition. The concern may be based on specifics in a patient‘s condition or history (or perhaps a family history or an occupational hazard). Feedback: Anticipatory guidance is the physician‘s offering suggestions for behavior modification or other preventive measures related to a patient‘s high risk for a condition. The concern may be based on specifics in a patient‘s condition or history (or perhaps a family history or an occupational hazard). Learning Objective: 24.05 Topic: Preventive Medicine Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: Global surgery package is a group of services already included in the code for the operation and not reported separately. Feedback:

Global surgery package is a group of services already included in the code for the operation and not reported separately. Learning Objective: 24.07 Topic: E/M in the Global Surgical Package Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: It can be a complex event to transfer the care and management of a patient‘s ongoing condition from one facility to another, especially when the new location will involve a new care team. Code 99495 (transitional care management services) requires the physician to document following elements: •Communication (direct contact, telephone, electronic) with the patient and/or care giver within two business days of discharge •Medical-decision making of at least moderate complexity during the service period •Face-to-face visit within 14 calendar days of discharge Feedback: It can be a complex event to transfer the care and management of a patient‘s ongoing condition from one facility to another, especially when the new location will involve a new care team. Code 99495 (transitional care management services) requires the physician to document following elements: •Communication (direct contact, telephone, electronic) with the patient and/or care giver within two business days of discharge •Medical-decision making of at least moderate complexity during the service period •Face-to-face visit within 14 calendar days of discharge Learning Objective: 24.10 Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Basics: 1. Answer: 99203

Feedback: Office or Other Outpatient Services 99203: Index>evaluation and management>office and other outpatient services>new patient A medically appropriate history and examination Medical decision making of low complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: 99214 Feedback: Office or Other Outpatient Services 99214: Index>evaluation and management>office or other outpatient services>established patient A medically appropriate history and examination MDM of moderate complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04

Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: 99222 Feedback: Hospital Observation Services 99222: Index>evaluation and management>hospital services>observation care>initial>new or established patient Comprehensive history Comprehensive examination MDM moderate complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services

Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: 99234 Feedback: Hospital Inpatient or Observation Services 99234: Index>evaluation and management>hospital services>inpatient or observation care>admission and discharge same day Detailed or comprehensive history Detailed or comprehensive exam Medical Decision Making is straightforward or low complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: 99244 Feedback: Consultations 99243: Index>evaluation and management>consultation>office or other outpatient consultation>new or established patient Detailed history Detailed examination MDM of moderate complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 6. Answer: 99283 Feedback: Emergency Department Services 99282: Index>evaluation and management>ED>new or established patient

Expanded problem focused history Expanded problem focused examination MDM of low complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 7. Answer: 99315 Feedback: Nursing Facility Services 99315: Index>evaluation and management>nursing facility>discharge day management>30 minutes or less Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10

Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 8. Answer: 99342 Feedback: Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services 99342: Index>Home Services>new patient visit Expanded problem focused history Expanded problem focused exam MDM of low complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply

CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 9. Answer: 99360 Feedback: Prolonged Services 99360: index>evaluation and management>standby services> 30 minutes Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes14. 10. Answer: 99471 Feedback: Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal Critical Care Services

99471: Index>evaluation and management>pediatric critical care>initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Practice: 1. Answer: 99205 Feedback: 99205: Index>evaluation and management>office or other outpatient services>new patient A medically appropriate history and examination MDM of high complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05

Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: 99212-25 Feedback: 99212-25: Index>evaluation and management>office or other outpatient services>established patient ~ append modifier -25 because patient came in for the tetanus shot and physician also evaluated a cut on hand~ Significant, Separately Identifiable ~ Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service A medically appropriate history and examination MDM of straightforward complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient

Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: 99221 Feedback: 99221: Index>evaluation and management>hospital>initial hospital care>new or established patient Detailed history Detailed examination MDM of low complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: 99231 Feedback: 99231: Index>evaluation and management>Hospital>subsequent hospital care Problem focused history Problem focused examination MDM of low complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: 99252 Feedback: 99252: Index>evaluation and management>consultation>inpatient consultation>new or established.

Problem focused history Problem focused examination MDM of straightforward complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 6. Answer: 99291, 99292x3 Feedback: 99291: Index>evaluation and management>critical care>first 30-74 minutes 99292x3: Index>evaluation and management>critical care>each additional 30 minutes 2.5 hours= 150 minutes – 74 minutes = 76 minutes / 30 minutes = 2.53 or 3 Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07

Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 7. Answer: 99310 Feedback: 99310: Index>evaluation and management>nursing facility>subsequent care Comprehensive interval history Comprehensive examination MDM of high complexity Be careful here; this is not a consultation. Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes

Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 8. Answer: 99316 Feedback: 99316: Index>evaluation and management>nursing facility>discharge day management; more than 30 minutes Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 9. Answer: 99344 Feedback:

99344: Index>evaluation and management>home or residence visit>new patient Detailed history Comprehensive exam MDM of moderate complexity You must meet all 3 key components. Remember, you can never code higher than your lowest key component. Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 10. Answer: 99379 Feedback: 99379: Index>evaluation and management>care plan oversight services>Nursing Facility>15-29 minutes Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07

Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 11. Answer: 99367 Feedback: 99367: Index>evaluation and management>case management services>medical team conference, without direct contact with patient and/or family>participation by physician qualified health care professional Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 12. Answer: 99403 Feedback: 99403: Index>preventive medicine>counseling>individual>intervention>new or established patient>approximately 45 minutes Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 13. Answer: 99455-32 Feedback: 99455-32: Index>evaluation and management>work-related and/or medical disability

Evaluation ~ append modifier -32 because it is a mandated encounter Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 14. Answer: 99461 Feedback: 99461: Index>evaluation and management>newborn care>initial care, per day, for evaluation and management of normal newborn infant seen in other than a hospital or birthing center Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09

Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 15. Answer: 99479 Feedback: 99479: Index>evaluation and management>low birth weight infant>subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant, 1500-2500 grams Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Application: Application 1: TURNER, CHARLES Answer: 99282 Feedback: 99282: Index>evaluation and management>ED>new or established patient Problem focused history Problem focused examination MDM of straightforward complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: BROMWELL, BRANDON Answer: 99213

Feedback: 99213: Index>evaluation and management>office or other outpatient services>established patient A medically appropriate history and examination MDM of low complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: HENSLEY, ERNEST Answer: 99242 Feedback: 99242: Index>evaluation and management>consultation>office or other outpatient consultation>new or established patient Expanded problem focused history Expanded problem focused examination MDM of straightforward complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05

Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: SARGENT, ALEXANDER Answer: 99347 Feedback: 99334: Index>evaluation and management>home or residence visit>established patient Problem focused history Problem focused examination MDM of straightforward complexity Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services

Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: LEAMAN, HESTER Answer: 99471 Feedback: 99471: Index>evaluation and management>pediatric critical care>initial inpatient pediatric critical care, per day, for evaluation and management of a critically ill infant or young child, 29 days through 24 months of age Learning Objective: 24.01 Learning Objective: 24.02 Learning Objective: 24.03 Learning Objective: 24.04 Learning Objective: 24.05 Learning Objective: 24.06 Learning Objective: 24.07 Learning Objective: 24.08 Learning Objective: 24.09 Learning Objective: 24.10 Topic: What Are E/M Codes? Topic: Location Where the E/M Services Were Provided Topic: Relationship between Provider and Patient Topic: Types of E/M Services Topic: Preventive Medicine Services Topic: Abstracting the Physician‘s Notes Topic: E/M in the Global Surgical Package Topic: E/M Modifiers and Add-On Codes Topic: Special Evaluation Services Topic: Coordination and Management Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 3-5 minutes Chapter 25. CPT Anesthesia Section 2024 Complaint Learning Outcomes

LO 25.1 Interpret the types of anesthesia provided. LO 25.2 Determine the accurate code and physical status modifier for the administration of anesthesia. LO 25.3 Incorporate the Official Guidelines for reporting. LO 25.4 Apply the formula for using time to report anesthesia services. LO 25.5 Select the accurate qualifying circumstances add-on codes. LO 25.6 Identify special circumstances requiring a CPT modifier. LO 25.7 Abstract the notes to append HCPCS Level II modifiers.

Chapter Outline Learning Outcomes Key Terms Types of Anesthesia Topical and/or Local Anesthesia Regional Anesthesia General Anesthesia Moderate (Conscious) Sedation Coding Anesthesia Services Physical Status Modifiers Anesthesia Guidelines Anesthesia Guidelines Anesthesia Code Package Time Reporting Qualifying Circumstances Special Circumstances Unusual Anesthesia Same Physician Administering Anesthesia and Performing the Proceudre HCPCS Level II Modifiers Chapter Summary Chapter 25 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application

Chapter Overview Show all students how to find the procedure codes for identifying the administration of anesthetics in the second section of the CPT book, directly after evaluation and management (E/M) codes. Have them note that the anesthesiology codes range from 00100–01999 and 99100–99140.

As future professional coders, your students should know they will typically use codes from this section only if they go to work for an anesthesiologist, in his or her office, or for a billing company that codes and files claims for anesthesiologists. Point out that generally, anesthesiologists have their own practices. While almost all of their services are provided in a hospital setting, coding will not be done as such because they are not employees of the hospital, and consequently they must submit their own claim forms to the insurance carrier for their services.

Discussion Activities

1. Modifiers and Add-on Codes: In your own words, explain why the physical status modifiers exist and qualifying circumstances codes are so important to the reimbursement for anesthesiologists. (Learning Outcome: 25.2. 25.5) Discuss the specific details provided by each of the physical status modifiers and the qualifying circumstances codes and how they report the level of work and expertise required by the anesthesiologist in those circumstances.

2. Time Reporting: Compare and contrast the two methods of reporting anesthesia services: Time reporting versus CPT code reporting. (Learning Outcome: 25.4) Review the process of time reporting calculations and compare the differences in information reported with this formula versus using CPT codes. Additional Resources Types of Anesthesia (American Society of Anesthesiologists): http://www.lifelinetomodernmedicine.com/Types-OfAnesthesia.aspx Anesthesia Fact Sheet (National Institutes of Health): http://www.nigms.nih.gov/Publications/factsheet_Anesthesia.htm Anesthesia (MedlinePlus): http://www.nlm.nih.gov/medlineplus/anesthesia.html General Anesthesia interactive tutorial (MedlinePlus): http://www.nlm.nih.gov/medlineplus/tutorials/generalanesthesia/htm/index.htm General Anesthesia (Mayo Clinic): http://www.mayoclinic.com/health/anesthesia/MY00100/METHOD=print Spinal and epidural anesthesia (MedlinePlus): http://www.nlm.nih.gov/medlineplus/ency/article/007413.htm Conscious Sedation (American Association of Nurse Anesthetists): http://www.aana.com/ForPatients.aspx?ucNavMenu_TSMenuTargetID=68&ucNavMenu_TSMenuTargetType =4&ucNavMenu_TSMenuID=6&id=298 American Society of Anesthesiologists: www.asahq.org/ American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org American Health Information Management Association: www.ahima.org AAPC: www.aapc.com

Chapter 25 Review CPT Anesthesia Section Answer Key Let’s Check It! Terminology Answer: 1. G Monitored Anesthesia Care (MAC) 2. A Anesthesia 3. I Topical Anesthesia 4. H Regional Anesthesia 5. E General Anesthesia 6. D Conscious Sedation 7. B Anesthesiologists 8. C Certified Registered Nurse Anesthetist (CRNA)

9. F Local Anesthesia 1. Learning Objective: 25.01 Learning Objective: 25.03 Topic: Types of Anesthesia Topic: Anesthesia Guidelines Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: B moderate sedation Feedback: While there are many types of anesthesia, they are all primarily divided into three preliminary categories: topical/local, regional, and general. Learning Objective: 25.01 Topic: Types of Anesthesia Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: C 00142-P1 Feedback: The correct anesthesia code for a normally health patient who has a corneal transplant. Would be 00142-P1: CPT index>anesthesia>eye>lens P1: physical status modifier=A normal healthy patient Learning Objective: 25.02 Topic: Coding Anesthesia Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 3.

Answer: A 23 Feedback: Unusual circumstances might require the administration of general anesthesia for a procedure that typically requires either local anesthesia or no anesthesia. In these cases, the modifier 23 Unusual Anesthesia must be appended to the procedure code for that basic service (not to the anesthesia code); you will not assign a code from the Anesthesia section of CPT. Learning Objective: 25.06 Topic: Special Circumstances Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 4. Answer: C monitored anesthesia care. Feedback: MAC is the acronym for monitored anesthesia care Learning Objective: 25.01 Topic: Types of Anesthesia Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: C 57 Feedback: Specific HCPCS Level II modifiers are designated for use with anesthesia service codes. These modifiers are used only if the insurance carrier, such as Medicare, accepts HCPCS Level II codes and modifiers. It is your responsibility, as a professional coder, to know the rules for the different third-party payers with which you will work. AA Anesthesia services performed personally by the anesthesiologist AD Medical supervision by a physician: more than 4 concurrent anesthesia procedures G8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure G9 Monitored anesthesia care (MAC) for a patient who has a history of a severe cardiopulmonary condition QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals

QS Monitored anesthesiology care services (can be billed by a qualified nonphysician anesthetist or a physician) QX Qualified nonphysician anesthetist with medical direction by a physician QY Medical direction of one qualified nonphysician anesthetist by an anesthesiologist QZ CRNA without medical direction by a physician The QY modifier would be used to indicate that an anesthesiologist was available and oversaw the administration of anesthesia services provided by someone else, such as a CRNA. The QY modifier is for the supervision of one case at a time. QK is used for two to four cases at one time, and AD is for more than four cases at one time. Learning Objective: 25.07 Topic: HCPCS Level II Modifiers Blooms: Hard CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: B be appended to the correct procedure code. Feedback: On those occasions when the same physician who performs the procedure also administers regional or general anesthesia, you must append modifier 47 Anesthesia by Surgeon to the appropriate procedure code. The modifier is not attached to an anesthesia procedure code; it is added to the basic procedure code. No additional code from the Anesthesia section will be used. Learning Objective: 25.02 Topic: Coding Anesthesia Services Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 7. Answer: D home health follow-up Feedback: The following services are included in the anesthesia code package and are not coded separately: • Usual preoperative visits • Anesthesia care during the procedure

• Administration of fluids • Usual monitoring services • Usual postoperative visits Learning Objective: 25.03 Topic: Anesthesia Guidelines Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 8. Answer: A (B + T + M) x CF Feedback: The formula used to calculate the amount of compensation the anesthesiologist will receive is: Compensation = (B+T+M) x CF Learning Objective: 25.04 Topic: Time Reporting Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: C severe systemic disease Feedback: The available add-on codes for qualifying circumstances are: +99100 Patient of extreme age . . . younger than 1 year or older than 70 years. +99116 Anesthesia complicated by total body hypothermia. +99135 Anesthesia complicated by controlled hypotension. +99140 Anesthesia complicated by emergency conditions. Learning Objective: 25.05 Topic: Special Circumstances Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: B mild systemic disease Feedback: The physical status modifiers are as follows: • P1 A normal healthy patient • P2 A patient with mild systemic disease • P3 A patient with severe systemic disease • P4 A patient with severe systemic disease that is a constant threat to life • P5 A moribund patient who is not expected to survive without the operation • P6 A declared brain-dead patient whose organs are being removed for donor purposes Learning Objective: 25.02 Topic: Coding Anesthesia Services Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute Let’s Check It! Guidelines: 1. Answer: anesthesia, five-digit Feedback: Services involving administration of anesthesia are reported by the use of the anesthesia five-digit procedure code plus modifier codes.

Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: moderate, 99151, 99152, 99153 Feedback: To report moderate (conscious) sedation provided by a physician also performing the service for which conscious sedation is being provided, see codes 99151, 99152, 99153. Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: facility, 99155, 99156, 99157, non-facility Feedback: When a second physician other than the health care professional performing the diagnostic or therapeutic services provides moderate (conscious) sedation in the facility setting, the second physician reports the associated moderate sedation procedure/service 99155, 99156, 99157; when these services are performed by the second physician in the non-facility setting codes 99155, 99156, 99157 would not be reported.

Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: minimal, deep, monitored Feedback: Moderate sedation does not include minimal sedation (anxiolysis), deep sedation or monitored anesthesia care. Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: time, ends, safely Feedback: Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision. Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: Medicine Feedback: ―Special Services and Reporting‖ are listed in the Medicine section. Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services

Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: over, above, separately, 99070 Feedback: Supplies and materials provided over and above those usually included in the office visit or other services rendered may be listed separately. Drugs, tray supplies and materials provided should be listed and identified with 99070 or the appropriate supply code. Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: multiple, single, complex, total Feedback:

When multiple surgical procedures are performed during a single anesthetic administration, the anesthesia code representing the most complex procedure is reported. The time reported is the combined total for all procedures. Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: All, plus, physical status modifier Feedback: All anesthesia services are reported by use of the anesthesia five-digit procedure code plus the addition of a physical status modifier. Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: ―P‖, 1 to 6 Feedback: Physical Status modifiers are represented by the initial letter ―P‖ followed by a single digit from 1 to 6. Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: When coding anesthetic services, you should follow these steps to find the best, most appropriate code. 1. Confirm that the physician who performed the procedure for which the anesthesia is necessary is a different professional from the person who administered the anesthesia. 2. Identify the anatomical site of the patient‘s body upon which the surgical procedure is being performed.

3. Confirm the exact surgical procedure performed, as documented in the physician‘s notes. 4. Consult the alphabetic index of the CPT book, look under the heading of Anesthesia, and read down the list to find the anatomical site shown below that heading. Identify the suggested code or codes for this site. 5. Turn to the numerical portion of the CPT book, Anesthesia section, and find the subsection identifying that anatomical site. 6. Read the descriptions written next to each code option suggested in the alphabetic index carefully. Feedback: When coding anesthetic services, you should follow these steps to find the best, most appropriate code. 1. Confirm that the physician who performed the procedure for which the anesthesia is necessary is a different professional from the person who administered the anesthesia. 2. Identify the anatomical site of the patient‘s body upon which the surgical procedure is being performed. 3. Confirm the exact surgical procedure performed, as documented in the physician‘s notes. 4. Consult the alphabetic index of the CPT book, look under the heading of Anesthesia, and read down the list to find the anatomical site shown below that heading. Identify the suggested code or codes for this site. 5. Turn to the numerical portion of the CPT book, Anesthesia section, and find the subsection identifying that anatomical site. 6. Read the descriptions written next to each code option suggested in the alphabetic index carefully. Learning Objective: 25.02 Topic: Coding Anesthesia Services Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: The following services are included in the anesthesia code package and are not coded separately:  Usual preoperative visits  Anesthesia care during the procedure  Administration of fluids  Usual monitoring services  Usual postoperative visits Feedback:

The following services are included in the anesthesia code package and are not coded separately:  Usual preoperative visits  Anesthesia care during the procedure  Administration of fluids  Usual monitoring services  Usual postoperative visits Learning Objective: 25.03 Topic: Anesthesia Guidelines Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: Time reporting may be used for billing general anesthesia services in certain areas or by certain third-party payers instead of CPT codes. The clock begins when the anesthesiologist starts to prepare the patient for the administration of the anesthetic drug in the OR and is typically measured in 15-minute increments. The time ends when the anesthesiologist is no longer required to be present, once the patient has been safely transferred to postoperative supervision. When multiple procedures are completed during the same operative session, the time calculated should be the total time for all the procedures performed. Feedback: Time reporting may be used for billing general anesthesia services in certain areas or by certain third-party payers instead of CPT codes. The clock begins when the anesthesiologist starts to prepare the patient for the administration of the anesthetic drug in the OR and is typically measured in 15-minute increments. The time ends when the anesthesiologist is no longer required to be present, once the patient has been safely transferred to postoperative supervision. When multiple procedures are completed during the same operative session, the time calculated should be the total time for all the procedures performed. Learning Objective: 25.04 Topic: Time Reporting Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: The available add-on codes for qualifying circumstances are: +99100 Patient of extreme age: younger than 1 year or older than 70 years. +99116 Anesthesia complicated by total body hypothermia. Hypothermia is defined as extremely low body temperature, below 36.1°C (97°F). +99135 Anesthesia complicated by controlled hypotension. Hypotension is defined as abnormally low blood pressure +99140 Anesthesia complicated by emergency conditions. An emergency is characterized as a situation in which the patient‘s life, or an individual body part, would be threatened if there were any delay in providing treatment. Feedback: The available add-on codes for qualifying circumstances are: +99100 Patient of extreme age: younger than 1 year or older than 70 years. +99116 Anesthesia complicated by total body hypothermia. Hypothermia is defined as extremely low body temperature, below 36.1°C (97°F). +99135 Anesthesia complicated by controlled hypotension. Hypotension is defined as abnormally low blood pressure +99140 Anesthesia complicated by emergency conditions. An emergency is characterized as a situation in which the patient‘s life, or an individual body part, would be threatened if there were any delay in providing treatment. Learning Objective: 25.05 Topic: Qualifying Circumstances Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: Modifier QX identifies: Qualified non-physician anesthetist with medical direction by a physician. Modifier QY identifies: Medical direction of one qualified non-physician anesthetist by an anesthesiologist Modifier QZ identifies: CRNA without medical direction by a physician Feedback: Modifier QX identifies: Qualified non-physician anesthetist with medical direction by a physician. Modifier QY identifies: Medical direction of one qualified non-physician anesthetist by an anesthesiologist

Modifier QZ identifies: CRNA without medical direction by a physician Learning Objective: 25.07 Topic: HCPCS Level II Modifiers Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Basics: 1. Answer: 00103-P2 Feedback: 00103-P2: Index>anesthesia>eyelid>P2 Physical status modifier P2: Patient with mild systemic disease Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: 42405-47 Feedback: 42405-47: Index>biopsy>salivary gland Physical Status modifier: P1: Normally healthy patient

Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: 01112-P3 Feedback: 01112-P3: Index>anesthesia>pelvis>bone marrow Physical status modifier P3: Patient with several systemic disease (anemia and congestive heart failure) Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4. Answer: 00851-P1 Feedback: 00851-P1: Index>anesthesia>tubal ligation Physical Status Modifier P1: Normal healthy patient Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 5. Answer: 00102-P1, 99100 Feedback: 00102-P1: Index>anesthesia>cleft lip repair 99100: Anesthesia for patient of extreme age, younger than 1 year and older than 70 Physical Status Modifier P1: Normal healthy patient Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07

Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 6. Answer: 00322-P1-AA Feedback: 00322-P1-AA: Index>anesthesia>thyroid>P1 Physical Status Modifier P1: Normal healthy patient Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 7. Answer: 00930-P1 Feedback:

00930-P1: Index>anesthesia>orchipexy>P1 Physical Status Modifier P1: Normal healthy patient Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: 00539-P1, 99140 Feedback: 00539-P1: Index>anesthesia>trachea>reconstruction. 99140: Anesthesia complicated by emergency conditions. Physical Status Modifier P1: Normal healthy patient Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 1-3 minutes 9. Answer: 01486-P3 Feedback: 01486-P3: Index>anesthesia>replacement>ankle>P3 Physical status modifier P3: Patient with severe systemic disease Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 10. Answer: 55250-47 Feedback: 55250-47: Index>vasectomy>47 Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia

Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: 32554-47 Feedback: 32554-47: index>thoracentesis Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 12. Answer: 01990-P6 Feedback: 01990-P6: index>anesthesia>transplantation>organ harvesting

Physical Status Modifier P6: A declared brain-dead patient whose organs are being removed for donor purpose Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 13. Answer: 01130-P1 Feedback: 01130-P1: index>anesthesia>cast application>pelvis Physical Status Modifier P1: Normal healthy patient Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3

CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 14. Answer: 01742-P4 Feedback: 01742-P4: index>anesthesia>osteotomy>humerus Physical Status Modifier P4: A patient with a severe systemic disease that is a constant threat to life Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 15. Answer: 01952-P2 Feedback: 01952-P2: index>anesthesia>burn>debridement and/or excision Physical Status Modifier P2: A patient with a mild systemic disease Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06

Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes You Code It! Practice: 1. Answer: 01960-P1 Feedback: 01960-P1: Index>anesthesia>childbirth>vaginal delivery>P1 Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2.

Answer: 01952-P1 Feedback: 01952-P1: Index>anesthesia>burns>debridement and/or excision>second- or third degree>with or without skin graft>between 4%-9% of total body surface area> P1 Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: 01522-P3 Feedback: 01522-P3: Index>anesthesia>leg>lower>venous thrombectomy>P3 Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances

Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: 00944-P3 Feedback: 00944-P3: Index>anesthesia>hysterectomy>vaginal>P3 Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: 00834-P5 Feedback: 00834-P5: Index>anesthesia>hernia repair>abdomen>lower>younger than 1 year of age>P5 Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05

Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: 00144-P3-AA, 99100 Feedback: 00144-P3-AA: Index>anesthesia>corneal transplant>P3 99100: Anesthesia for patient of extreme age, younger than 1 year and older than 70 Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes

7. Answer: 00214-P1 Feedback: 00214-P1: Index>anesthesia>ventriculography>P1 Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: 00635-P2 Feedback: 00635-P2: Index>anesthesia>lumbar puncture>P2 Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: 01382-P1 Feedback: 01382-P1: Index>anesthesia>arthroscopic procedure>knee>P1 Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: 01744-P1 Feedback: 01744-P1: Index>anesthesia>humerus>repair of nonunion or malunion of humerus Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia

Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: 99151, 99153 Feedback: 99151: Index>sedation>moderate>younger than 5 years of age 99153: Index>sedation>moderate>additional 10 minutes Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: 01967-P1, 01968 Feedback: 01967-P1: Index>anesthesia>childbirth>vaginal delivery>P1

01968: Index>anesthesia>childbirth>cesarean delivery Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: 00402-P1 Feedback: 00402-P1: Index>anesthesia>breast>reconstruction Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: 00561-P5-AA Feedback: 00561-P5-AA: Index>anesthesia>heart>pericardial sac and great vessels of the chest; with pump oxygenator, younger than 1 year of age Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: 00832-P3-AA, 99100 Feedback: 00832-P3-AA: Index>anesthesia>hernia repair>abdomen>lower>ventral and incisional hernias 99100: Anesthesia for patient of extreme age, younger than 1 year and older than 70 Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia

Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application: Application 1: PERSILE, LORRAINE Answer: 01400-P1-AA Feedback: 01400-P1-AA: Index>anesthesia>arthroscopic procedure>knee Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: HAMMOND, NEIL Answer: 00600-P2-AA

Feedback: 00600-P2-AA: Index>anesthesia>spine and spinal cord>cervical Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: WAYMEN, MARK Answer: 00830-P1-AA Feedback: 00830-P1-AA: Index>anesthesia>hernia repair>abdomen>lower Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: DRESSLER, SIMONE Answer: 00790-P1-AA Feedback: 00790-P1-AA: Index>anesthesia>abdomen>intraperitoneal>upper abdomen>laparoscopy Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: LYNDON, JAMES Answer: 01810-P1-AA Feedback: 01810-P1-AA: Index>anesthesia>hand>on nerves, muscles, tendons, fascia, and bursae of forearm, wrist, and hand Learning Objective: 25.01 Learning Objective: 25.02 Learning Objective: 25.03 Learning Objective: 25.04 Learning Objective: 25.05 Learning Objective: 25.06 Learning Objective: 25.07 Topic: Types of Anesthesia Topic: Coding Anesthesia Services Topic: Anesthesia Guidelines

Topic: Time Reporting Topic: Qualifying Circumstances Topic: Special Circumstances Topic: HCPCS Level II Modifiers Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 26. CPT Surgery Section 2024 Compliant Learning Outcomes

LO 26.1 Distinguish among the types of surgical procedures. LO 26.2 Determine which services are included in the global surgical package. LO 26.3 Interpret the impact on coding of the global time frames. LO 26.4 Identify unusual services and treatments and report them accurately. LO 26.5 Abstract physician documentation of procedures on the integumentary system. LO 26.6 Apply the guidelines, accurately, for coding procedures on the musculoskeletal system. LO 26.7 Recognize the details required to accurately report procedures on the respiratory system. LO 26.8 Identify guidelines to correctly report services to the cardiovascular system. LO 26.9 Distinguish the various procedures on the digestive system. LO 26.10 Ascertain the elements of coding services to the urinary system. LO 26.11 Determine how to accurately report procedures on the genital systems: male and female. LO 26.12 Interpret documentation to accurately report procedures on the nervous system. LO 26.13 Recognize the necessary details to report procedures on the eye, ocular adnexa, and auditory system. LO 26.14 Report accurately the different services provided during an organ transplant. LO 26.15 Demonstrate the proper way to report the use of an operating microscope with a CPT code.

Chapter Outline Learning Outcomes Key Terms Types of Surgical Procedures

Prophylactic, Diagnostic, and Therapeutic Procedures Surgical Approaches The Surgical Package Services Always Included Services Not Included Global Period Time Frames Unusual Services and Treatments Treatment Plan Provided by More Than One Physician Increased Procedural Services Separate Procedure Integumentary System Incision and Drainage (I&D) Debridement Biopsies Excisions Reexcision Repair (Closures) Adjacent Tissue Transfer and/or Rearrangement Skin Replacement Surgery and Flaps Destruction Mohs Micrographic Surgery Musculoskeletal System Cast Application Fracture Reduction Penetrating Trauma Wounds Bone Grafts and Implants Spine Arthrodesis Skeletal Fixation Spinal Procedures Spinal Fusion Lumbar Puncture Respiratory System Sinus Endoscopy Pleural and Lung Biopsies Cardiovascular System Pacemakers Implantable Defribrillators Leadless Pacemakers Bypass Grafting Arteries and Veins Endovascular Repair of Abdominal Aorta and/or Iliac Arteries Catheterizations and Vascular Families Central Venous Access Procedures Digestive System Endoscopic Procedures Gastric Intubation Hernia Repair Bariatric Surgery Urinary System Urinary Catheterization Urodynamics Transurethral Surgery Percutaneous Genitourinary Procedures The Genital Systems: Male and Female The Male Genital System The Female Genital System Nervous System Skull Surgery

Spinal Cord Injury Repair Pain Management Endovascular Therapy The Optical and Auditory Systems Optical System Glaucoma Surgery Vitrectomy Foreign Object in Eye Dacryocystorhinostomy The Auditory System The Outer Ear The Middle Ear The Inner Ear Tympanostomy Organ Transplantation Lung Transplantation Heart/Lung Transplantation Liver Transplantation Pancreas Transplantation Renal (Kidney) Transplantation Operating Microscope Chapter Summary Chapter 26 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code IT! Basics You Code It! Practice You Code It! Application

Chapter Overview Your students have learned that typically, a surgical procedure can be performed in any one of several locations: the physician’s office, an ambulatory care center, or a hospital. Of course, the location will most often be determined by the intensity or complexity of the procedure. Help the students understand that they certainly would not expect an entire operating room at the hospital to be used for the physician to perform a simple repair of a laceration (cut), and no one could imagine agreeing to have a heart transplant performed in a physician’s office. Point out that as a coding specialist, they will have a different responsibility depending upon where they work, when it comes to coding surgical procedures. In addition, there may be more than one coding specialist involved in one procedure. Ask your students to look up the term surgery in their CPT books. They will see that the term surgery does not limit itself to include only those services and treatments performed in an operating room, or even in a hospital. Within this section of the CPT book, codes are listed that report: o Incision and drainage of a cyst o Debridement o Simple repair of a superficial wound Help the students understand that all of these services can easily be performed in a physician’s office. In addition, there are many procedures that are now performed at an ambulatory surgical center or outpatient department that was once performed in hospital settings. Remind the students that in Chapter 7 they began learning about coding surgical procedures involving the Integumentary system. Chapter 8 continues from that point through the balance of the Surgery section of CPT.

Discussion Activities 1. Identify the five elements included in the Surgical or Global Package. Explain, in your own words, what each represents. Explain, in your own words, why each is included in the surgical codes. (Learning Outcome: 26.2) Discuss with students the components of the surgical (global) package and why these services are grouped together, included in the reimbursement for the procedure itself.

2. Discuss the components of the various levels of wound repair. (Learning Outcome: 26.5) Direct students to the CPT guidelines under the header Repair (Closure) above code 12001, the fact that they need to be familiar with these instructions and understand them, and can reference them whenever required. 3. Identify a procedure performed on the spine. List the details of the procedure required to determine the correct code from the documentation. State if the procedure is an inpatient or outpatient surgical procedure. (Learning Outcome: 26.6) Remind students to read the in-section guidelines carefully. Review details such as anterior or posterior approaches, and if a graft is used, or not. Additional Resources Videos of Surgical Procedures (MedlinePlus): http://www.nlm.nih.gov/medlineplus/surgeryvideos.html Mohs Surgery (Medicine.Net): http://www.medicinenet.com/mohs_surgery/article.htm Skin Cancer and Plastic Surgery (American Society of Plastic Surgeons): http://www.plasticsurgery.org/Patients_and_Consumers/Procedures/Reconstructive_Procedures/Skin_Cancer_ and_Your_Plastic_Surgeon.html Skin Graft Overview (University of Maryland Medical Center): http://www.umm.edu/ency/article/002982.htm American College of Surgeons: www.facs.org/ American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org American Health Information Management Association: www.ahima.org AAPC: www.aapc.com

Chapter 26 Review CPT Surgery Section Answer Key Let’s Check It! Terminology Part I: Answer: 1. E Global Period 2. F Harvesting 3. B Donor Area 4. K Surgical Approach 5. J Standard of Care 6. A Complex Closure 7. C Excision 8. H Recipient Area 9. G Intermediate Closure 10. I Simple closure 11. D Full-Thickness 1. Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.05 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Integumentary System

Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part II: Answer: 1. G Open Treatment 2. C Closed Treatment 3. H Percutaneous Skeletal Fixation 4. E Laminectomy 5. I Saphenous Vein 6. A Allotransplantation 7. J Transplantation 8. B Arthrodesis 9. F Manipulation 10. D Fornix Learning Objective: 26.06 Learning Objective: 26.08 Learning Objective: 26.14 Topic: Musculoskeletal System Topic: Cardiovascular System Topic: Organ Transplantation Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: Part I: 1. Answer: B general anesthesia Feedback: General anesthesia is not included in the global surgical package. Once the physician and patient agree to move forward with the operation or procedure, the surgical package includes the following elements: • Evaluation and management (E/M) encounters provided after the decision to have surgery.

• Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia. • The operation itself, along with any services normally considered a part of the procedure being performed. • Immediate postoperative care. • Follow-up care. • Supplies provided in a physician‘s office. Learning Objective: 26.02 Topic: The Surgical Package Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 2. Answer: D the standard of care Feedback: All procedures have assigned global period time frames based on the standard of care for a treatment or service. These range from 0 (zero) for a very simple procedure to 10 days for a minor procedure to 90 days for major surgery. Learning Objective: 26.03 Topic: Global Period Time Frames Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 3. Answer: C Biopsy Feedback: A diagnostic procedure or test is performed so that the physician can gather more details about the condition or concern at issue. In other words, the reason for performing the test or procedure is to get closer to an accurate diagnosis. A biopsy is not included in the global surgical package. Biopsies are performed, most often, for diagnostic purposes. These procedures are done to obtain a sampling of cells or piece of tissue from the body that can then be pathologically analyzed. The surgical package includes the following elements:  Evaluation and management (E/M) encounters provided after the decision to have surgery.



Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia.  The operation itself, along with any services normally considered a part of the procedure being performed.  Immediate postoperative care.  Follow-up care.  Supplies provided in a physician‘s office. Learning Objective: 26.01 Topic: Types of Surgical Procedures Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 4. Answer: C 58 Feedback: Modifier -58 identifies a Staged or multipart procedures. Each stage or operation has its own surgical package and global period for aftercare. You must add modifier 58 to the second procedure code and all additional procedure codes reported for that same encounter. Learning Objective: 26.02 Topic: The Surgical Package Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 5. Answer: A 54 Feedback: When more than one physician will be involved in providing all the necessary services for one patient having one operation appended modifiers explain to the third-party payer who did what and when. Modifier -54 identifies Surgical Care Only. You must add this modifier to the correct CPT surgical procedure code when your physician is only going to perform the procedure itself, and not provide or be involved in any preoperative or postoperative care of the patient. Learning Objective: 26.04 Topic: Unusual Services and Treatments

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: C with each lesion coded separately Feedback: When the physician removes a lesion from a patient, you must code the excision of each lesion separately. Learning Objective: 26.05 Topic: Integumentary System Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 7. Answer: D Simple Feedback: The code for the excision of a lesion includes the administration of a local anesthetic and a simple closure of the excision site. Learning Objective: 26.05 Topic: Integumentary System Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 8. Answer: A 58 Feedback: If the reexcision is performed during a subsequent, or later, encounter during the postoperative period, you should attach modifier -58 Staged Procedure to the procedure code for that second excision. The reexcision to remove additional tissue around the original site during the postoperative period would directly apply to modifier -58‘s description: (b) more extensive than the original procedure.

Learning Objective: 26.05 Topic: Integumentary System Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: C adding all the lengths together and coding the total. Feedback: When multiple wounds are repaired with the same complexity on the same anatomical site(s) as indicated by the code descriptor, add all the lengths together to use one code for the total repair. Learning Objective: 26.05 Topic: Integumentary System Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: B the type of donor. Feedback: The type of donor is not included in the elements that determine the most accurate code for skin grafts. The codes for skin grafts are determined by three things: 1. The size of the recipient area (the size of the wound to be grafted) 2. The location of the recipient area (the anatomical site) 3. The type of graft (e.g., pinch graft, split graft, full-thickness graft, etc.) Learning Objective: 26.05 Topic: Integumentary System Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute Part II:

1. Answer: B cast Feedback: Codes in the musculoskeletal subsection already include the application and removal of a cast or traction device as a part of the procedure performed. If a second cast or traction device is required during the total course of treatment for the injury or condition, then the application and removal of any additional cast or traction device should be coded separately from the Applications of Casts and Strapping subsection, codes 29000–29799. Learning Objective: 26.06 Topic: Musculoskeletal System Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 2. Answer: D Semicircular canals Feedback: The Inner Ear • Semicircular canals. • Cochlea. The Middle Ear • Auditory ossicles: malleus, incus, and stapes. • Oval window. • Eustachian tube (auditory tube) connects the middle ear to the nasopharynx (throat). Learning Objective: 26.13 Topic: The Optical and Auditory Systems Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: C 32098 Feedback: Thoracotomy, with biopsy of pleura would be coded 32098 32098: index>incision>pleura>biopsy Learning Objective: 26.07

Topic: Respiratory System Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 4. Answer: D the preparation of the organ. Feedback: Backbench work is the actual preparation of the organ prior to the transplant procedure. Learning Objective: 26.14 Topic: Organ Transplantation Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 5. Answer: C 35572 Feedback: When an arterial graft is performed, use codes from the range 33533–33545. All these codes include the use of grafts from the internal mammary artery, gastroepiploic artery, epigastric artery, radial artery, and arterial conduits harvested from other sites. Use one of the following codes (in addition to the code for the bypass procedure) if the graft is harvested from another site: • From an upper extremity artery, add code 35600. • From an upper extremity vein, add code 35500. • From the femoropopliteal vein, use code 35572. Learning Objective: 26.08 Topic: Cardiovascular System Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6.

Answer: C 56631 Feedback: 56631 is the correct code for a vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy. 56631: index>vulvectomy>radical>partial> with unilateral inguinofemoral lymphadenectomy. Learning Objective: 26.11 Topic: The Genital Systems: Male and Female Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: D pacemaker Feedback: The code for an endovascular repair of an iliac aneurysm include 1. Introduction, positioning, and operation of an endovascular graft of the iliac artery (common, hypogastric, or external). 2. All balloon angioplasty and/or stent deployments within the treatment area. Learning Objective: 26.08 Topic: Cardiovascular System Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 8. Answer: C 43644 Feedback: The correct code for a laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy of 145 cm would be 43644. 43644: CPT index> Roux-en-Y procedure Learning Objective: 26.09 Topic: Digestive System Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 0-1 minute 9. Answer: B extensive dural grafting. Feedback: Code 62263 includes the following:  Percutaneous insertion of an epidural catheter.  Removal of the catheter several days later.  Procedure injections.  Fluoroscopic guidance and localization.  Multiple adhesiolysis sessions over the course of 2 or more days. Learning Objective: 26.12 Topic: Nervous System Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: B modifier 26. Feedback: If the physician for whom you are coding did not actually perform the procedure but only interpreted the results, then the appropriate procedure code from this section should be appended with modifier 26 Professional Component. Learning Objective: 26.10 Topic: Urinary System Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Let’s Check It! Guidelines: 1. Answer: Introduction Feedback: Guidelines to direct general reporting for services are presented in the Introduction.

Learning Objective: 26.01

Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: Management Feedback: Services rendered in the office, home or hospital consultations and other medical services are listed in the Evaluation and Management Services section. Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03

Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: Follow-up, only Feedback: Follow-up care for diagnostic procedures includes only that care related to recovery from the diagnostic procedure itself. Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07

Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: diagnostic, concomitant, separately Feedback: Care of the condition for which the diagnostic procedure was performed or of other concomitant conditions is not included and may be listed separately. Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11

Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: therapeutic, usually, surgical Feedback: Follow-up care for therapeutic surgical procedure includes only that care which is usually a part of the surgical service. Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15

Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: one, date, session, post-operative, modifiers Feedback: When more than one procedure/services is performed on the same date, same session or during a post-operative period, several CPT modifiers may apply. Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames

Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: ―separate procedure‖, addition, integral Feedback: The code designated as ―separate procedure‖ should not be reported in addition to the code for the total procedure or service of which it is considered an integral component. Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System

Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: designated, independently, itself, 59, component Feedback: However, when a procedure or service that is designated as a ―separate procedure‖ is carried out independently or considered to be unrelated or distinct from other procedures/services provided at that time, it may be reported by itself, or in addition to other procedures/services by appending modifier 59 to the specific ―separate procedure‖ code to indicate that the procedure is not considered to be a component of another procedure, but is a distinct, independent procedure. Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System

Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: guidance, supervision, guidelines, Radiology Feedback: When imaging guidance or imaging supervision and interpretation is included in a surgical procedure, guidelines for image documentation and report, included in the guidelines for Radiology will apply. Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System

Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: destruction, technique, management Feedback: Surgical destruction is a part of a surgical procedure and different methods of destruction are not ordinarily listed separately unless the technique substantially alters the standard management of a problem or condition. Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female

Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Rules and Regulations: 1. Answer: A prophylactic treatment is one that is performed to prevent a condition from developing. This may be a surgical procedure, a series of injections, or a prescription. A diagnostic procedure or test is performed so the physician can gather more details about the condition or concern at issue. In other words, the reason for performing the test or procedure is to get closer to an accurate diagnosis. A therapeutic procedure is provided, most often, to correct or fix a problem. Feedback: A prophylactic treatment is one that is performed to prevent a condition from developing. This may be a surgical procedure, a series of injections, or a prescription. A diagnostic procedure or test is performed so the physician can gather more details about the condition or concern at issue. In other words, the reason for performing the test or procedure is to get closer to an accurate diagnosis. A therapeutic procedure is provided, most often, to correct or fix a problem. Learning Objective: 26.01 Topic: Types of Surgical Procedures Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: Throughout the CPT book, you will see code descriptions that include the notation ―separate procedure.‖ Such services and treatments are generally performed along with a group of other procedures. When this happens, you will be able to find a combination, or bundled, code that includes all the treatments

together. However, this particular procedure can also be performed alone. If so, you would use the code for the ―separate procedure.‖ Feedback: Throughout the CPT book, you will see code descriptions that include the notation ―separate procedure.‖ Such services and treatments are generally performed along with a group of other procedures. When this happens, you will be able to find a combination, or bundled, code that includes all the treatments together. However, this particular procedure can also be performed alone. If so, you would use the code for the ―separate procedure.‖ Learning Objective: 26.04 Topic: Unusual Services and Treatments Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: The formula is: Coded size of lesion = size of lesion + (size of margins ×2) Feedback: The formula is: Coded size of lesion = size of lesion + (size of margins ×2) Learning Objective: 26.05 Topic: Integumentary System Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: Intermediate closure (repair): A multilevel method of sealing an opening in the skin involving one or more of the deeper layers of the skin. (Note: Single – layer closure of heavily contaminated wounds that required extensive cleaning or removal of particulate matter also constitutes intermediate repair.) Complex closure (repair): A method of sealing an opening in the skin involving a multilayered closure and a reconstructive procedure such as scar revision, debridement, or retention sutures. Feedback: Intermediate closure (repair): A multilevel method of sealing an opening in the skin involving one or more of the deeper layers of the skin. (Note: Single – layer closure of heavily contaminated wounds that required extensive cleaning or removal of particulate matter also constitutes intermediate repair.)

Complex closure (repair): A method of sealing an opening in the skin involving a multilayered closure and a reconstructive procedure such as scar revision, debridement, or retention sutures. Learning Objective: 26.05 Topic: Integumentary System Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: When a surgeon performs microsurgery, he or she has to use an operating microscope. In such cases, you must code the use of the microscope (69990) in addition to the procedure in which the microscope is used. +69990 Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure.) Feedback: When a surgeon performs microsurgery, he or she has to use an operating microscope. In such cases, you must code the use of the microscope (69990) in addition to the procedure in which the microscope is used. +69990 Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure.) Learning Objective: 26.15 Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Basics: 1. Answer: aspiration, 10005 Feedback: Dr. Ladd performs a fine needle aspiration using ultrasound-guidance imaging; first lesion: aspiration, 10005 10005: Index>aspiration>fine needle>with imaging guidance Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05

Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 2. Answer: paring, 11057 Feedback: Dr. Dingle performs paring of 6 soft corn lesions: paring, 11057 11057: Index>paring>skin lesion>benign hyperkeratoic>6 Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08

Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 3. Answer: removal, 11200 Feedback: Dr. Gunter removals 10 skin tags: removal, 11200 11200: Index>removal>skin tags>10 Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11

Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 4. Answer: insertion, 11981 Feedback: Dr. Strobel performs an insertion of a non-biodegradable drug delivery contraception implant: insertion, 11981 11981: Index>insertion>drug delivery implant Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13

Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 5. Answer: cryotherapy, 17340 Feedback: Dr. Amerson performs cryotherapy for acne: cryotherapy, 17340 17340: Index>cryotherapy>acne Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures

Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 6. Answer: wound, 20103 Feedback: Mark Latham was accidentally shot in the arm, Dr. Quattlebaum explores and enlarges the wound to remove the bullet. Code the exploration of the wound: exploration, 20103 20103: Index>wound>exploration>penetrating>extremity Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package

Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 7. Answer: external fixation, 20690 Feedback: Dr. Hunter applies a uniplane external fixation device for temporary stabilization of a radial fracture: external fixation, 20690 20690: Index>external fixation>application>uniplane Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments

Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 8. Answer: arthroscopy, 29827 Feedback: Dr. Preston performs an arthroscopic repair of a rotator cuff tear: arthroscopy, 29827 29827: Index>arthroscopy>surgical>shoulder Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System

Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 9. Answer: pacemaker, 33214 Feedback: Roy has an implanted single chamber pacemaker, Dr. Terrence removes the existing pulse generator and tests the existing lead and inserts a new dual chamber system for an upgrade: pacemaker, 33214 33214: Index>pacemaker>upgrade Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System

Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 10. Answer: craniotomy, 61315 Feedback: Dr. Shumpert performs a craniotomy to removes a hematoma; intracerebellar: infratentorial craniotomy, 61315 61315: Index>craniotomy>evacuation of hematoma Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System

Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 11. Answer: chemical peel, 15788 Feedback: Dr. Wattel performs an epidermal facial chemical peel: chemical peel, 15788 15788: Index>chemical peel>facial; epidermal Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System

Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 12. Answer: reconstruction, 19364 Feedback: Dr. Rudner performs a breast reconstruction with free flap: reconstruction, 19364 19364: Index>reconstruction>breast>with free flap Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation

Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 13. Answer: excision, 11623 Feedback: Dr. Payton excises a malignant lesion which measured 2.9 cm with margins: excision, 11623 11623: Index>lesion>skin>excision>malignant>2.1 cm to 3.0 cm Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply

CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 14. Answer: excision, 15940 Feedback: Dr. Charne excises an ischial pressure ulcer with a primary suture: excision, 15940 15940: Index>excision>ulcer>pressure>ischium>primary suture Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3

CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 15. Answer: burns, 16020 Feedback: Dorothy Loman had a small partial thickness burn on her hand. Dr. Beariman performed a debridement and dressing of the injury: burns, 16020 16020: Index>burns>dressing and/or debridement of partial-thickness burns, initial or subsequent, small. Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes You Code It! Practice: 1. Answer: 12034 Feedback: 12034: Index>wound>scalp>intermediate>7.6 cm to 12.5 cm 2.0 + 4.5 + 1.0 + 1.0 = 8.5 cm Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: 26951-22-FA Feedback: 26951-22-FA: Index>amputation>thumb Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3.

Answer: 32557 Feedback: 32557: Index>drainage>pleura>with image guidance Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: 52601 Feedback: 52601: Index>prostate>resection>transurethral Learning Objective: 26.01 Learning Objective: 26.02

Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: 63005, 62360-58 Feedback: 63005: Index>laminectomy>for decompression>lumbar 62360-58: Index>infusion therapy>spinal>device implantation/replacement> subcutaneous reservoir Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04

Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: 11623 Feedback: 11623: Index>excision>skin>malignant>2.1 cm to 3.0 cm Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09

Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: 11005, 11008 Feedback: 11005: Index>debridement>skin>subcutaneous tissue>infected 11008: Index>removal>mesh>abdominal wall Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12

Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: 33270, 33272, 33241, 99152, 99153 Feedback: 33270: Index>implantable defibrillator>replacement>system 33272: Index>implantable defibrillator>removal>electrodes 33241: Index>implantable defibrillator>removal>pulse generator 99152: Index>sedation>moderate>patient older than 5 years of age 99153: Index>sedation>moderate>patient>additional 10 minutes Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12

Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: 69210-50 Feedback: 69210-50: Index>removal>ear wax>auditory canal, external Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures

Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: 50020-79 Feedback: 50020-79: Index>drainage>abscess>renal Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System

Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: 21480 Feedback: 21480: Index>dislocation>temporomandibular>closed treatment>initial Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System

Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: 31725, 99152 Feedback: 31725: Index>catheter>aspiration>tracheobronchial with fiberscope, bedside 99152: Index>sedation>moderate>patient older than 5 years of age Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System

Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: 43847 Feedback: 43847: Index>reconstruction>stomach>for obesity>with small intestine reconstruction to limit absorption Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: 33944 Feedback: 33944: Index>transplantation>heart>allograft preparation>backbench standard preparation of cadaver donor heart allograft prior to transplantation Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3

CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: 65275 Feedback: 65275: Index>cornea>repair>wound>non-perforating Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium

Est Time: 3-5 minutes You Code It! Application: Application 1: PENNETTA, OSCAR Answer: 12032, 12002-59 Feedback: 12032: Index>wound>repair>leg>intermediate>2.6 cm to 7.5 cm (5.1 cm) 12002-59: Index>wound>repair>arm/hand>simple>2.6 cm to 7.5 cm (2.0 + 3.0 = 5.0 cm) Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: DRESDEN, NELDA Answer: 15273, 15274 Feedback: 15273: Index>skin substitute graft>arms>first 100 sq cm wound surface area 15274: Index>skin substitute graft>arms>each additional 100 sq cm wound surface area, or part thereof Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: APPON, CYNTHIA Answer: 63081, 22600, 22842, 20936 Feedback: 63081: Index>vertebral>corpectomy 22600: Index>arthrodesis>cervical>below C2>posterior technique, single level 22842: Index>instrumentation>spinal>insertion 20936: Index>autograft>spine Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: WHEATON, MARLA Answer: 57522 Feedback: 57522: Index>LEEP procedure>loop electrode excision Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: UPTON, MAXINE Answer: 36555, 99151, J2250 Feedback: 36555: Index>insertion>catheter>venous>access device>younger than 5 years 99151: Index>sedation>moderate>patient younger than 5 years of age J2250: HCPCS Index>drug table>Versed>1 mg>IM Learning Objective: 26.01 Learning Objective: 26.02 Learning Objective: 26.03 Learning Objective: 26.04 Learning Objective: 26.05 Learning Objective: 26.06 Learning Objective: 26.07 Learning Objective: 26.08 Learning Objective: 26.09 Learning Objective: 26.10 Learning Objective: 26.11 Learning Objective: 26.12 Learning Objective: 26.13 Learning Objective: 26.14 Learning Objective: 26.15 Topic: Types of Surgical Procedures Topic: The Surgical Package Topic: Global Period Time Frames Topic: Unusual Services and Treatments Topic: Integumentary System Topic: Musculoskeletal System Topic: Respiratory System Topic: Cardiovascular System Topic: Digestive System Topic: Urinary System Topic: The Genital Systems: Male and Female Topic: Nervous System Topic: The Optical and Auditory Systems Topic: Organ Transplantation Topic: Operating Microscope Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3

CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 27: CPT Radiology Coding 2024 Compliant Learning Outcomes

LO 27.1 Distinguish the different types of imaging. LO 27.2 Abstract the different reasons for imaging services. LO 27.3 Identify the technical components from professional components. LO 27.4 Apply the guidelines accurately regarding the number of views. LO 27.5 Apply the guidelines to determine how to code the administration of contrast materials. LO 27.6 Recognize diagnostic radiologic services. LO 27.7 Interpret accurately into CPT codes to report mammography services. LO 27.8 Discern how to report bone and joint studies. LO 27.9 Decide when to code radiation treatments. LO 27.10 Determine how to accurately report nuclear medicine services.

Chapter Outline Learning Outcomes Key Terms Types of Imaging X-Rays (Radiography) Computed Tomography (CT) Scans Magnetic Resonance Imaging (MRI) Positron Emission Tomography (PET) Nuclear Medicine Fluoroscopy Ultrasound (Sonography) Angiograph Purposes for Imaging Screening vs. Diagnostic Image Guidance Technical vs. Professional Number of Views Procedures With or Without Contrast Diagnostic Radiology Diagnostic Angiography Diagnostic Venography Transcatheter Procedures Diagnostic Ultrasound Mammography Bone and Joint Studies

Radiation Oncology Nuclear Medicine

Chapter Summary Chapter 27 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application

Chapter Overview Healthcare professionals use radiologic imaging to help them see inside the body. These services can be used to investigate a potential condition (diagnostically), measure the progress of a disease or condition, or to aid in the actual reduction or prevention of disease or other condition (therapeutically), also called interventional radiology. Many, many years ago, this department was simply known as x-ray, because this was the extent of the equipment. Now, technology has made tremendous advancements in the science of imaging, and healthcare professionals can diagnose, monitor, and treat patients much more effectively and efficiently.

Discussion Activities 1. Compare and contrast the various types of imaging techniques. Why might a physician order one type of imaging verses another? What details does a coder need to know to determine the correct code? Explain the differences between the screening and the diagnostic service. (Learning Outcome: 27.1) a. Radiology (x-rays) b. CT scans c. MRIs d. Sonogram Ask students to highlight specific terms in each category’s code descriptions, such as how many views for x-rays, with or without contrast for MRIs, or pregnant or not for abdominal sonograms. 2.

Review the differences between technical and professional services. Exactly what are the tasks involved in each component? How does a coder know if one or the other or both are being provided? (Learning Outcome: 27.3)

This discussion can lead to an overview of freestanding imaging centers, hospital radiology departments, and physician’s offices with in-house imaging equipment. Additional Resources Mammography (Medline Plus):http://www.nlm.nih.gov/medlineplus/mammography.html Coronary angiogram (Mayo Clinic): http://www.mayoclinic.com/health/coronary-angiogram/MY00541 Angiography Test (Cleveland Clinic):http://my.clevelandclinic.org/services/angiography/hic_angiography_test.aspx Nuclear Medicine (American College of Radiology): http://www.radiologyinfo.org/en/info.cfm?pg=gennuclear Radiation Oncology (Cleveland Clinic): http://my.clevelandclinic.org/services/radiation_oncology/default.aspx?WT.mc_id=1283&utm_campaign=rad onc-redirect&utm_medium=offline&utm_source=redirect Radiation Oncology (UCLA): http://radonc.ucla.edu/ Radiologic Spinal Procedures (Pg 11–16): Coding for Spinal Procedures (AHIMA): campus.ahima.org/audio/2009/RB102209.pdf American College of Radiology: www.acr.org/ American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org American Health Information Management Association: www.ahima.org AAPC: www.aapc.com

Chapter 27 Review CPT Radiology Answer Key Let’s Check It! Terminology 1. Answer: 1. K Venography 2. J Sonogram 3. A Angiography 4. E Fluoroscope 5. G Magnetic Resonance Imaging (MRI) 6. C Computed Tomography (CT) 7. I Radiation 8. B Arthrography 9. H Nuclear Medicine 10. F Magnetic Resonance Arthrography (MRA) 11. D Computed Tomography Angiography (CTA) Learning Objective: 27.03 Learning Objective: 27.06 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Technical vs. Professional Topic: Diagnostic Radiology Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: B interpretation of the imaging. Feedback: The professional component is coded to gain reimbursement for the health care professional, radiologist, or physician who supervises and interprets the images taken. Learning Objective: 27.03 Topic: Technical vs. Professional Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 2. Answer: D testing the equipment. Feedback: Health care professionals use radiologic imaging to see inside the body. Radiologic services, also known as interventional radiology, can be used to investigate a potential condition (diagnostically), measure the progress of a disease or condition, or aid in the actual reduction or prevention of disease or other condition (therapeutically). Learning Objective: 27.01 Topic: Types of Imaging Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 3. Answer: D 78015 Feedback: 78015 is the correct CPT radiology code for a thyroid carcinoma metastases imaging; limited area (neck and chest only). 78015: Index>thyroid gland>nuclear medicine>imaging for metastases Learning Objective: 27.10 Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 4. Answer: A administered a substance to enhance the image. Feedback: The phrase ―with contrast‖ means that the technician or physician gave the patient a substance to enhance the image. Learning Objective: 27.05 Topic: Procedures With or Without Contrast Blooms: Remember CAAHEP: IX.C.1

CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 5. Answer: B with that code plus the modifier 52. Feedback: In those cases, when the radiologist takes fewer than the minimum number of views included in the description, you have to append the radiologic code with modifier 52 Reduced Services. 52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician‘s discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Learning Objective: 27.04 Topic: Number of Views Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: C catheter placement. Feedback: Therapeutic transcatheter radiologic supervision and interpretation codes, when associated with intervention, already include: 1. Vessel measurement. 2. Postangioplasty or stent venography. 3. Contrast injections, angiography/venography, road mapping, and/or fluoroscopic guidance for the interventional procedure. Learning Objective: 27.06 Topic: Diagnostic Radiology Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute

7. Answer: C right posterior oblique. Feedback: RPO stands for Right posterior oblique: At an angle from the right back. Learning Objective: 27.04 Topic: Number of Views Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 8. Answer: B therapeutic purposes. Feedback: Radiation is performed in the treatment of malignant neoplasms and other carcinomas for therapeutic purpose. Learning Objective: 27.09 Topic: Radiation Oncology Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 9. Answer: D a radiologic exam. Feedback: An x-ray is a radiologic exam. Learning Objective: 27.01 Topic: Types of Imaging Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 10. Answer: C tracers, tracers Feedback:

Nuclear medicine uses tiny quantities of radioactive material, also known as tracers, in conjunction with a scintillation or gamma camera to record the emissions from the tracers to create an image of the anatomical site. Learning Objective: 27.10 Topic: Nuclear Medicine Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute Let’s Check It! Guidelines: 1. Answer: rarely, new Feedback: A service that is rarely provided, unusual, variable, or new may require a special report. Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes

2. Answer: Imaging, access Feedback: Imaging may be required during the performance of certain procedures or certain imaging procedures may require surgical procedures to access the imaged area.

Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: not, stated Feedback: Many services include image guidance, which is not separately reportable and is so stated in the descriptor or guidelines. Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09

Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: surgical, Medicine, service Feedback: When imaging is not included in a surgical procedure or procedure from the Medicine section, image guidance codes or codes labeled ―radiological supervision and interpretation‖ may be reported for the portion of the service that requires imaging. Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: ―with contrast‖, enhancement Feedback: The phrase ―with contrast‖ used in the codes for procedures performed using contrast for imaging enhancement represents contrast material administered intravascularly, intra-articularly, or intrathecal. Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: joint Feedback: For intra-articular injection, use the appropriate joint injection code. Learning Objective: 27.01

Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: arthrography Feedback: If radiographic arthrography is performed, also use the arthrography supervision and it interpretation code for the appropriate joint. Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast

Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: without, injection, MR, needle Feedback: If computed tomography or magnetic resonance arthrography are performed without radiographic arthrography, use the appropriate joint injection code, the appropriate CT or MR code, and the appropriate imaging guidance code for needle placement for contrast injection. Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes

9. Answer: intravascular Feedback: Injection of intravascular contrast material is part of the ―with contrast‖ CT, computer tomographic angiography, magnetic resonance imaging and magnetic resonance angiography procedure. Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: contrast, qualify Feedback: Oral and/or rectal contrast administration alone does not qualify as a study ―with contrast.‖ Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07

Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: signed, integral Feedback: A written report signed by the interpreting individual should be considered an integral part of a radiology procedure or interpretation. Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply

CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 12. Answer: descriptors, analog Feedback: With regard to CPT descriptors for radiography services, ―images‖ refer to those acquired in either an analog or digital manner. Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: Technical component: Coded to gain reimbursement for the facility that owns and maintains the equipment used; amortized cost of the machine, supplies, maintenance, overhead (electricity, etc.), and the technician.

Professional component: Coded to gain reimbursement for the health care professional, radiologist, or physician who supervises and interprets the images taken. Feedback: Technical component: Coded to gain reimbursement for the facility that owns and maintains the equipment used; amortized cost of the machine, supplies, maintenance, overhead (electricity, etc.), and the technician. Professional component: Coded to gain reimbursement for the health care professional, radiologist, or physician who supervises and interprets the images taken. Learning Objective: 27.03 Topic: Technical vs. Professional Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: Identifying whether an imaging service is performed as a screening or a diagnostic tool can be important to determining the correct code for the procedure. This designation refers to the reason why the physician ordered the test. A screening image is one done as part of a regular preventive check-up. This is ordered because the standard of care and the calendar have matched up. For example, a screening mammogram will be ordered the same time every year for a woman over the age of 50. There are no signs or symptoms that would prompt the test. It is just the wise thing to do to make certain all is fine. A diagnostic image is one that is taken to assist in the identification and/or confirmation of a suspected condition or diagnosis. In these cases, the physician would identify specific signs or symptoms that led him or her to decide this test was needed. Feedback: Identifying whether an imaging service is performed as a screening or a diagnostic tool can be important to determining the correct code for the procedure. This designation refers to the reason why the physician ordered the test. A screening image is one done as part of a regular preventive check-up. This is ordered because the standard of care and the calendar have matched up. For example, a screening mammogram will be ordered the same time every year for a woman over the age of 50. There are no signs or symptoms that would prompt the test. It is just the wise thing to do to make certain all is fine. A diagnostic image is one that is taken to assist in the identification and/or confirmation of a suspected condition or diagnosis. In these cases, the

physician would identify specific signs or symptoms that led him or her to decide this test was needed. Learning Objective: 27.02 Topic: Purposes for Imaging Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: There are times when an imaging session for a patient begins as a screening test and becomes a diagnostic test while the patient is still there. With technology providing instant imaging, the radiologist can actually review the images almost immediately after they have been taken, while the patient is still on the premises. This eliminates a patient‘s needing to come back at another time to retake an image that was not clear or the technician has to take additional views because the radiologist identified a suspicious element. When a screening test turns into a diagnostic test, report only the diagnostic imaging service because that will include the screening aspect of the procedure. Feedback: There are times when an imaging session for a patient begins as a screening test and becomes a diagnostic test while the patient is still there. With technology providing instant imaging, the radiologist can actually review the images almost immediately after they have been taken, while the patient is still on the premises. This eliminates a patient‘s needing to come back at another time to retake an image that was not clear or the technician has to take additional views because the radiologist identified a suspicious element. When a screening test turns into a diagnostic test, report only the diagnostic imaging service because that will include the screening aspect of the procedure. Learning Objective: 27.02 Topic: Purposes for Imaging Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer:

Radiation oncology is performed in the treatment of malignant neoplasms and other carcinomas, commonly known as cancer. The codes in this subsection already include certain services: • Initial consultation. • Clinical treatment planning. • Simulation. • Medical radiation physics. • Dosimetry (the determination of the correct dosage). • Treatment devices. • Special services. • Clinical treatment management procedures. • Normal follow-up care during treatment and for 3 months following the completion of the treatment. Feedback: Radiation oncology is performed in the treatment of malignant neoplasms and other carcinomas, commonly known as cancer. The codes in this subsection already include certain services: • Initial consultation. • Clinical treatment planning. • Simulation. • Medical radiation physics. • Dosimetry (the determination of the correct dosage). • Treatment devices. • Special services. • Clinical treatment management procedures. • Normal follow-up care during treatment and for 3 months following the completion of the treatment. Learning Objective: 27.09 Topic: Radiation Oncology Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: There are several different types of nuclear medicine tests used to identify a health concern: • Bone scans are used to investigate injuries (fractures, sprains, and strains) as well as tumors. • Thyroid uptake scans are used to assess thyroid function and record the structure of the gland.

• Heart scans are used to measure heart function, evaluate the existence and extent of heart muscle damage after a heart attack, and gauge the blood flow to the heart muscle. • Lung scans are used to determine the presence of blood clots. In addition, scans can be valuable to calculate the flow of air into and out of the lungs. • Hepatobiliary scans can provide information to evaluate the function of the liver and the gallbladder. • Gallium scans can be used to identify the presence of infection and some types of tumors. Feedback: There are several different types of nuclear medicine tests used to identify a health concern: • Bone scans are used to investigate injuries (fractures, sprains, and strains) as well as tumors. • Thyroid uptake scans are used to assess thyroid function and record the structure of the gland. • Heart scans are used to measure heart function, evaluate the existence and extent of heart muscle damage after a heart attack, and gauge the blood flow to the heart muscle. • Lung scans are used to determine the presence of blood clots. In addition, scans can be valuable to calculate the flow of air into and out of the lungs. • Hepatobiliary scans can provide information to evaluate the function of the liver and the gallbladder. • Gallium scans can be used to identify the presence of infection and some types of tumors. Learning Objective: 27.10 Topic: Nuclear Medicine Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes You Code It! Basics: 1. Answer: X-ray, 70030 Feedback: Dr. Gray takes an eye x-ray for detection of foreign body: X-ray, 70030 70030: Index>x-ray>eye Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05

Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: CT scan, 72193 Feedback: Dr. Robertson takes a CT of the pelvis with contrast: CT scan, 72193 72193: Index>CT scan>with contrast>pelvis Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology

Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: Ultrasound, 76770 Feedback: Dr. Banks performs a renal ultrasound, complete, real-time with image documentation: Ultrasound, 76770 76770: Index>ultrasound>retroperitoneal Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4. Answer: X-ray, 70355 Feedback: Dr. Hicks takes a panoramic x-ray: X-ray, 70355

70355: Index>x-ray>panoramic Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 5. Answer: Brachytherapy, 77762 Feedback: Dr. Louche administers intracavitary radiation, 8 sources, brachytherapy: Brachytherapy, 77762 77762: Index>brachytherapy>intracavitary application Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging

Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 6. Answer: Nuclear medicine or SPECT, 78803 Feedback: Dr. Pullets performs a liver SPECT with vascular flow tomography: Nuclear medicine or SPECT, 78803 78803: Index>nuclear medicine>diagnostic>liver>vascular flow Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 1 Easy Est Time: 1-3 minutes 7. Answer: Positron emission tomography or PET, 78459 Feedback: Dr. Roof completes PET imaging of a heart: Positron emission tomography or PET, 78459 78459: Index>positron emission tomography>heart Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 8. Answer: Ureter, 78740 Feedback: Dr. Darby performs a ureteral reflux study: Ureter, 78740 78740: Index>ureter>reflux study Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05

Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 9. Answer: X-ray, 71100 Feedback: Dr. Allister takes a unilateral x-ray of ribs, 2 views: X-ray, 71100 71100: Index>x-ray>ribs Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology

Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 10. Answer: Kidney, 78700 Feedback: Dr. Alexander completes a Kidney imaging morphology: Ureter, 78700 78700: Index>Kidney>Nuclear Medicine>Imaging Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 11. Answer: Dual x-ray absorptiometry or DXA, 77080 Feedback: Dr. Steiner performs a DXA scan: Dual x-ray absorptiometry or DXA, 77080 77080: Index>dual x-ray absorptiometry>axial skeleton

Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 12. Answer: Nuclear Medicine, 78306 Feedback: Dr. Smyth completes a bone and joint Nuclear Medicine imaging; whole body:

Nuclear Medicine, 78306 78306: Index>nuclear medicine>body and joint>whole body Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional

Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 13. Answer: Radiopharmaceutical therapy, 79440 Feedback: Dr. Benton performs radiopharmaceutical therapy by intra-articular administration: Radiopharmaceutical therapy, 79440 79440: Index> radiopharmaceutical therapy>intra-articular Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy

Est Time: 1-3 minutes 14. Answer: Angiography, 75716 Feedback: Dr. Gilbert completes an angiography, extremity (arm), bilateral, radiological supervision and interpretation: Angiography, 75716 75716: Index>angiography>arm artery Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 15. Answer: MRI, 72148 Feedback: Dr. Johannson performs a MRI, spinal canal and contents, lumbar; without contrast material: MRI, 72148 72148: Index>magnetic resonance imaging>diagnostic>spine>lumbar Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05

Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes You Code It! Practice: 1. Answer: 76818 Feedback: 76818: Index>fetal non-stress test>ultrasound Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies

Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: 73552-RT Feedback: 73552-RT: Index>x-ray>femur>2 views Modifier RT identifies right side. Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: 78598 Feedback:

78598: Index>perfusion>imaging>pulmonary>quantitative differential pulmonary perfusion and ventilation including imaging when performed Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: 70481-RT Feedback: 70481-RT: Index>CT scan>with contrast>orbit Modifier RT identifies right side. Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging

Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: 77402 Feedback: 77402: Index>radiation therapy>treatment delivery>single area>single port>simple block> > 1 MeV Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: 77067 Feedback: 77067: Index>mammography>with computer-aided detection Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: 74185 Feedback: 74185: Index>magnetic resonance angiography>diagnostic>abdomen Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07

Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: 70250, 70551 Feedback: 70250: Index>x-ray>skull>less than 4 views 70551: Index>magnetic resonance imaging>diagnostic>brain>without contrast Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: 78300 Feedback: 78300: Index>nuclear medicine>diagnostic>bone and joint>imaging>limited area Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: 77261 Feedback: 77261: Index>radiation therapy>planning>simple Learning Objective: 27.01

Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: 79101 Feedback: 79101: Index>radiopharmaceutical therapy>intravenous Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology

Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: 78608 Feedback: 78608: Index>positron emission tomography>brain>metabolic evaluation Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: 76886 Feedback:

76886: Index>ultrasound>hip>infant>limited, static Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: 78803-LT Feedback: 78803-LT: Index>SPECT>kidney imaging Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views

Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: 76856 Feedback: 76856: Index>ultrasound>pelvis>complete Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes

You Code It! Application: Application 1: SAVOY, MARCELLA Answer: 72146, 74176 Feedback: 72146: Index>magnetic resonance (e.g. proton) imaging>diagnostic> spinal> thoracic>without contrast material 74176: Index>computed tomography>without contrast> abdomen Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: JAQUARD, JOEL Answer: 70250, 70491, 70551 Feedback: 70250: Index>x-ray>skull>less than 4 views 70491: Index>CT>with contrast>neck

70551: Index>magnetic resonance imaging>diagnostic>brain>without contract Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: BURMAN, CECILIA Answer: 70551, 70544, 70547 Feedback: 70551: Index>Magnetic Resonance Imaging>Diagnostic>Brain> without contrast 70544: Index>Magnetic Resonance Angiography>Head>without contrast 70547: Index>Magnetic Resonance Angiography>Neck>without contrast Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08

Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: TREMONT, GARETT Answer: 71046, 74019 Feedback: 71046: Index>X-Ray>Chest>2 views, frontal and lateral 74019: Index>X-Ray>Abdomen>2 views Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology

Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: WILLARD, NADINE Answer: 70496 Feedback: 70496: Index>computed tomographic (CT) angiography>head Learning Objective: 27.01 Learning Objective: 27.02 Learning Objective: 27.03 Learning Objective: 27.04 Learning Objective: 27.05 Learning Objective: 27.06 Learning Objective: 27.07 Learning Objective: 27.08 Learning Objective: 27.09 Learning Objective: 27.10 Topic: Types of Imaging Topic: Purposes for Imaging Topic: Technical vs. Professional Topic: Number of Views Topic: Procedures With or Without Contrast Topic: Diagnostic Radiology Topic: Mammography Topic: Bone and Joint Studies Topic: Radiation Oncology Topic: Nuclear Medicine Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 28. CPT Pathology & Laboratory Section 2024 Complaint

Learning Outcomes LO 28.1 Recognize key factors involved in pathology testing. LO 28.2 Identify testing methodologies and sources. LO 28.3 Report panel codes when qualified. LO 28.4 Analyze blood test reports to ensure accurate reporting. LO 28.5 Discern clinical chemistry studies. LO 28.6 Interpret details about molecular diagnostic testing. LO 28.7 Distinguish immunologic, microbiologic, and cytopathologic testing. LO 28.8 Abstract the correct details to report surgical pathology testing. LO 28.9 Append the correct modifier, when required. LO 28.10 Accurately interpret the abbreviations used most often in pathology and laboratory reports.

Chapter Outline Learning Outcomes Key Terms Specimen Collection and Testing Testing Methodology and Desired Results Types of Test Results Testing Methodologies Panels Blood Test Documentation Clinical Chemistry Molecular Diagnostics Pharmacogenomic Testing Immunology, Microbiology, and Cytopathology Immunology Microbiology Cytopathology and Cytogenetic Studies Surgical Pathology Reading the Lab Report Pathologic Testing on Bone Marrow Modifiers for Laboratory Coding Pathology and Lab Abbreviations Chapter Summary Chapter 28 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Guidelines Let’s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application

Chapter Overview In this chapter, your students will learn about coding pathology services. Explain to them that as physicians and health care professionals work to help their patients, usually they need the assistance of medical science to guide them. This guidance frequently comes from tests performed by professionals working in a laboratory, studying the evolution of a patient’s disease. Discussion Activities 3. Discuss the guidelines regarding using panel codes. (Learning Outcome: 28.3) Panel codes can be confusing. Have students review the components of each panel, why there are certain tests grouped into these panels, and what to do when all tests in a panel are not performed as well as what to do when more than the tests in a panel are performed. 4.

Explain the difference between gross and microscopic examination. (Learning Outcome: 28.8)

Surgical pathology may have only a gross examination of the specimen, in which case, a different code is used. Discuss why this may be the case. Also, take this time to review each of the surgical pathology levels (Level I through VI) and why one organ may be listed in two different levels. Additional Resources Laboratory Tests (MedlinePlus): http://www.nlm.nih.gov/medlineplus/laboratorytests.html Lab Tests Online: http://www.labtestsonline.org/understanding/ Physician’s Guide to Laboratory Tests Selection and Interpretation (mobile phone app): http://www.arupconsult.com/ Laboratory Tests (US FDA): http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/LabTest/default.htm Understanding Lab Test Results (Quest Diagnostics): http://www.questdiagnostics.com/kbase/topic/special/zp3409/sec1.htm CLIA: http://www.cms.gov/clia/ American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org American Health Information Management Association: www.ahima.org AAPC: www.aapc.com Coding for COVID-19 Testing As you all know, Coronavirus 2, aka COVID-19, is the first pandemic on earth in many decades. In order to track pathological testing being done to identify COVID-19 throughout the United States, and the world, new codes have been implemented. These are codes used to report the provision of the actual testing (by the laboratory) to determine if a patient has the virus or if the patient had the virus and now has antibodies. The antibody codes can also be reported for testing to confirm the efficacy of the vaccines. 86328 86413 86769 87426

87636

Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (eg. reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARSCoV, SARS-CoV-2 [COVID-19]) Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe

87637

87811

technique Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19])

Chapter 28 Review Pathology and Lab Answer Key Let’s Check It! Terminology 1. Answer: 1. A Cytology 2. H Quantitative 3. J Surgical Pathology 4. E Microscopic Examination 5. D Laboratory 6. F Pathology 7. C Gross Examination 8. B Etiology 9. I Specimen 10. G Qualitative Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.07 Learning Objective: 28.08 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1.

Answer: D LFT Feedback: The correct abbreviation for a liver function test is LFT. Learning Objective: 28.10 Topic: Pathology and Lab Abbreviations Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: B 86921, 86921 Feedback: The correct code for a compatibility test by incubation techniques for 2 units is 86921x2 86921: CPT index>compatibility test>blood Learning Objective: 28.07 Topic: Immunology, Microbiology, and Cytopathology Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 3. Answer: D all of these. Feedback: The specimen sent to the lab for testing may be from any number of different sources: patient‘s blood, urine, or other bodily fluids; tissue; or other part of the body. Learning Objective: 28.01 Topic: Specimen Collection and Testing Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 4. Answer: C code the tests individually.

Feedback: If the lab performs fewer than all the tests listed in a panel, you must code the tests separately; you are not permitted to use the panel code. Learning Objective: 28.03 Topic: Panels Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 5. Answer: C quantitative Feedback: The guidelines tell you that, if the documentation does not specify, you may assume that the examination performed was quantitative. Learning Objective: 28.02 Topic: Testing Methodology and Desired Results Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 6. Answer: B blood glucose Feedback: The lab tests that are most commonly performed use chemical processes to distinguish qualities and quantities of elements in the specimens provided. Typically, the specimens are samples of a patient‘s blood or urine. Blood glucose (sugar) is used to diagnose conditions such as diabetes mellitus (hyperglycemia) or hypoglycemia. Learning Objective: 28.05 Topic: Clinical Chemistry Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 7.

Answer: D 91 Feedback: 91-Repeat Clinical Diagnostic Laboratory Test: In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Learning Objective: 28.09 Topic: Modifiers for Laboratory Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: D HCT Feedback: Hematocrit (HCT): This test identifies the percentage of RBCs, which is used to identify anemia. Low counts may indicate bone marrow damage or vitamin deficiency, while high counts may indicate congenital heart disease, renal problems, or pulmonary disease. Normal range: 34%–45%. Learning Objective: 28.04 Topic: Blood Test Documentation Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 9. Answer: A gross examination Feedback: Surgical pathology is the study of tissues removed from a living patient during a surgical procedure. Codes 88300–88309 represent six levels of surgical pathologic testing. The codes include accession, the testing itself, and the written report from the pathologist. The codes (with the exception of 88300) also include both gross examination (also known as macroscopic examination) of the specimen and microscopic examination. Learning Objective: 28.08 Topic: Surgical Pathology Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 10. Answer: C Genetic Feedback: Genetic testing involves the analysis of specimens to identify any presence of a genetic disorder. Research and technology have developed testing methodologies for more than 2,000 diseases that can be performed to provide peace of mind, or early detection of diseases and conditions that are passed from parents to child via their genes. Learning Objective: 28.06 Topic: Molecular Diagnostics Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Guidelines 1. Answer: technologists, physician Feedback: Services in Pathology and Laboratory are provided by a physician or by technologists under responsible supervision of a physician. Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology

Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: multiple, same, separate Feedback: It is appropriate to designate multiple procedures that are rendered on the same date by separate entries. Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: 85999 Feedback:

Unlisted hematology and coagulation procedure is represented by code 85999. Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: rarely, may, special Feedback: A service that is rarely provided, unusual, variable or new may require a special report. Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels

Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: definition, extent, effort Feedback: Pertinent information should include an adequate definition or description of the nature, extent and need for the procedure; and the time, effort and equipment necessary to provide the service. Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: Pathology is the study of the nature, etiology, development, and outcomes of disease. Etiology is the study of the causes of disease. Feedback: Pathology is the study of the nature, etiology, development, and outcomes of disease. Etiology is the study of the causes of disease. Learning Objective: 28.01 Topic: Specimen Collection and Testing Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: Quantitative is the counting or measurement of something. Qualitative is the determination of character or essential element(s). Feedback: Quantitative is the counting or measurement of something. Qualitative is the determination of character or essential element(s). Learning Objective: 28.02 Topic: Testing Methodology and Desired Results Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: Cytology is the study of one cell at a time to discover abnormal cells present in tissue or bodily fluids. Cytologic testing is used to detect cancer cells and infectious organisms and to screen for fetal abnormalities. Specimens used in cytopathologic testing are obtained by fine-needle aspirations (as in amniocentesis), scraping of tissue surfaces (as in Pap

smears), and collection of bodily fluids (as with sputum or seminal fluid, or sperm). Feedback: Cytology is the study of one cell at a time to discover abnormal cells present in tissue or bodily fluids. Cytologic testing is used to detect cancer cells and infectious organisms and to screen for fetal abnormalities. Specimens used in cytopathologic testing are obtained by fine-needle aspirations (as in amniocentesis), scraping of tissue surfaces (as in Pap smears), and collection of bodily fluids (as with sputum or seminal fluid, or sperm). Learning Objective: 28.07 Topic: Immunology, Microbiology, and Cytopathology Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: Surgical pathology is the study of tissues removed from a living patient during a surgical procedure. Its purpose, much like other testing and studies, is to provide the information necessary to diagnose a disease or condition and to set forth a treatment plan. In such cases, all the steps (taking the specimen, testing, diagnosis, and treatment) may occur during one surgical session. The benefit of this quick and immediate process is that there is less trauma for the patient, who has to undergo anesthesia and an invasive procedure only once. In addition, it saves money for the patient, the facility, and the third-party payer. Feedback: Surgical pathology is the study of tissues removed from a living patient during a surgical procedure. Its purpose, much like other testing and studies, is to provide the information necessary to diagnose a disease or condition and to set forth a treatment plan. In such cases, all the steps (taking the specimen, testing, diagnosis, and treatment) may occur during one surgical session. The benefit of this quick and immediate process is that there is less trauma for the patient, who has to undergo anesthesia and an invasive procedure only once. In addition, it saves money for the patient, the facility, and the third-party payer. Learning Objective: 28.08 Topic: Surgical Pathology Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: If your health care facility uses an outside laboratory that bills your office, you include the charges for the lab work on the claim form that you file. In such instances, you must append the CPT code for the lab test with modifier 90. Modifier 90 - Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding modifier 90 to the usual procedure code. Feedback: If your health care facility uses an outside laboratory that bills your office, you include the charges for the lab work on the claim form that you file. In such instances, you must append the CPT code for the lab test with modifier 90. Modifier 90 - Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding modifier 90 to the usual procedure code. Learning Objective: 28.09 Topic: Modifiers for Laboratory Coding Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Basics: 1. Answer: Therapeutic drug assay, 80162 Feedback: Dr. McElory completes a drug monitoring of the digoxin: Therapeutic drug assay, 80162 80162: Index>therapeutic drug assay>digoxin>total Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05

Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: Bleeding, 85002 Feedback: Dr. Gavin performs a bleeding time test: Bleeding, 85002 85002: Index>bleeding>time Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding

Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: Tuberculosis, 86580 Feedback: Dr. Kaufmann completes a tuberculosis skin test: Tuberculosis, 86580 86580: Index>tuberculosis>skin test Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4. Answer: Crossmatch, 86825 Feedback:

Dr. Lovece performs a HLA crossmatch test, first dilution: Crossmatch, 86825 86825: Index>crossmatch Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 5. Answer: Compatibility, 86920 Feedback: Dr. Sox completes a blood typing compatibility test by spin technique: Compatibility, 86920 86920: Index>compatibility>blood Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10

Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 6. Answer: Culture, 87086 Feedback: Dr. Dickenson performs a urine bacterial culture quantitative colony count: Culture, 87086 87086: Index>culture>bacteria>urine Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 7. Answer: Hepatitis antigen, 87340 Feedback: Dr. Campos performs a HBsAg (hepatitis B surface antigen) test: Hepatitis antigen, 87340 87340: Index>hepatitis antigen>detection>immunoassay>B surface Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 8. Answer: Necropsy, 88040 Feedback: Dr. Hearon performs a forensic necropsy: Necropsy, 88040 88040: Index>necropsy>forensic exam

Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 9. Answer: Cryopreservation, 89337 Feedback: Dr. Busby completes a mature oocytes cryopreservation: Cryopreservation, 89337 89337: Index>cryopreservation>freezing and storage>reproductive tissue>oocytes Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing

Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 10. Answer: Blood cell count, 85004 Feedback: Dr. Klausing performs a blood cell count with automated differential WBC count: Blood cell count, 85004 85004: index>Blood Cell Count>Differential WBC Count Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 11. Answer: Creatine kinase, 82550 Feedback: Dr. Reilly completed a creatine kinase, total: Creatine kinase, 82550 82550: index>creatine kinase>total Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 12. Answer: Syphilis test, 86592 Feedback: Dr. Flemington performs a RPR syphilis test: Syphilis test, 86592 86592: index>Syphilis Test Learning Objective: 28.01 Learning Objective: 28.02

Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 13. Answer: Cytomegalovirus. 86645 Feedback: Dr. Jensen completes a CMV cytomegalovirus antibody IgM: Cytomegalovirus. 86645 86645: index>cytomegalovirus>Antibody>IgM Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation

Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 14. Answer: Bilirubin, 82248 Feedback: Dr. Vance performs a bilirubin, total; direct test: Bilirubin, 82248 82248: CPT manual>index>Bilirubin>Total>Direct Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes

15. Answer: Coombs test, 86880 Feedback: Dr. Humphrey completes a direct Coombs test: Coombs test, 86880 86880: CPT manual>index>Coombs test>direct Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes You Code It! Practice: 1. Answer: 85025 Feedback: 85025: Index>blood cell count>complete (CBC) Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05

Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: 80055 Feedback: 80055: Index>blood tests>panels>obstetric Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding

Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: 80428 Feedback: 80428: Index>growth hormone>growth hormone stimulation panel Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: 87177 Feedback: 87177: Index>smear and stain>ova and parasites smear

Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: 89259 Feedback: 89259: Index>cryopreservation>freezing and storage>reproductive tissue>sperm Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels

Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: 82274 Feedback: 82274: Index>occult blood>by hemoglobin immunoassay Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes

7. Answer: 80305 Feedback: 80305: Index>drug assay>drug procedure>presumptive drug class Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: 80184 Feedback: 80184: Index>therapeutic drug assay>phenobarbital Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08

Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: 80434 Feedback: 80434: Index>insulin>panels>for ACTH insufficiency Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: 81000 Feedback: 81000: Index>urinalysis Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: 86703 Feedback: 86703: Index>HIV-1>antibody detection>immunoassay Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03

Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: 86592 Feedback: 86592: Index>syphilis test Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology

Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: 88267 Feedback: 88267: Index>chromosome analysis>amniotic fluid Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: 88309

Feedback: 88309: Index>pathology and laboratory>surgical pathology>gross and micro exam>level VI>pancreas, total/subtotal resection Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: 88720 Feedback: 88720: Index>bilirubin>total>transcutaneous Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing

Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application: Application 1: MEDFORD, ROBERT Answer: 80053 Feedback: 80053: Index>blood tests>panels>metabolic>comprehensive Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: INGER, TERRENCE Answer: 88305 Feedback: 88305: Index>pathology and laboratory>surgical pathology>gross and micro>Level IV>skin Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: WALLER, FELIX Answer: 88304 Feedback:

88304: Index>pathology and laboratory>surgical pathology>gross and micro exam>level III> gallbladder Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: DALTON, ANGELA Answer: 88305 Feedback: 88305: Index>pathology and laboratory>surgical pathology>gross and micro exam>level IV> colon, biopsy Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10

Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: PRIMERO, GINO Answer: 88309 Feedback: 88309: Index> pathology and laboratory>surgical pathology>gross and micro exam>level VI> soft tissue tumor, extensive resection Learning Objective: 28.01 Learning Objective: 28.02 Learning Objective: 28.03 Learning Objective: 28.04 Learning Objective: 28.05 Learning Objective: 28.06 Learning Objective: 28.07 Learning Objective: 28.08 Learning Objective: 28.09 Learning Objective: 28.10 Topic: Specimen Collection and Testing Topic: Testing Methodology and Desired Results Topic: Panels Topic: Blood Test Documentation Topic: Clinical Chemistry Topic: Molecular Diagnostics Topic: Immunology, Microbiology, and Cytopathology Topic: Surgical Pathology Topic: Modifiers for Laboratory Coding Topic: Pathology and Lab Abbreviations Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 29: CPT Medicine Coding 2024 Compliant

Learning Outcomes

LO 29.1 Interpret the guidelines for coding the administration of immunizations. LO 29.2 Apply the guidelines to accurately report injections and infusions. LO 29.3 Determine the correct coding parameters for reporting psychiatric services. LO 29.4 Abstract physicians’ notes to accurately report dialysis and gastroenterology services. LO 29.5 Identify specifics to correctly report ophthalmology and otorhinolaryngologic services. LO 29.6 Determine how to accurately report cardiovascular services. LO 29.7 Recognize the details required for accurately reporting pulmonary function testing. LO 29.8 Report accurately the provision of immunology services. LO 29.9 Interpret the specifics for accurately reporting neurologic services. LO 29.10 Abstract the required details for reporting physical medical and rehabilitation services. LO 29.11 Employ the guidelines to accurately report alternative medicine services: acupuncture, osteopathic, and chiropractic treatments. LO 29.12 Abstract documentation for reporting special and other services. Chapter Outline Learning Outcomes Key Terms Immunizations Injections and Infusions Multiple Administrations Chemotherapy Administration Psychiatry, Psychotherapy, and Biofeedback Telemedicine Synchronous Services Dialysis and Gastroenterology Services Dialysis Hemodialysis End-Stage Renal Disease (ESRD) Gastroenterology Services Ophthalmology and Otorhinolaryngologic Services Ophthalmology Otorinolaryngologic Services Cardiovascular Services Cardiovascular Therapeutic Services

Cardiography Implantable and Wearable Cardiac Device Evaluations Echocardiography Cardiac Catheterization Electrophysiological Procedures Noninvasive Vascular Studies Pulmonary Pulmonary Function Testing Allergy and Clinical Immunology Neurology and Neuromuscular Procedures Central Nervous System Assessments Physical Medicine and Rehabilitation Acupuncture, Osteopathic and Chiropractic Treatments Acupuncture Osteopathic Manipulative Treatments Chiropractic Manipulative Treatment Other Services Provided Education and Training for Patient Self-Management Non–Face-To-Face Nonphysician Services Special Services, Procedures, and Reports Medication Therapy Management Services Home Health Procedures/Services Chapter Summary Chapter 29 Review Let‘s Check It! Terminology Let‘s Check It! Concepts Let‘s Check It! Guidelines Let‘s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application

Chapter Overview The Medicine section of the CPT book provides you with codes for other services that are supplied by health care professionals and not represented in the other sections of the CPT book. Services reported using codes from this section include:  Flu shots  Vaccinations for the kids to go back to school  Allergy shots  Chiropractic services  Psychotherapy  Dialysis  Hearing evaluations  Vision checks  Chemotherapy  Acupuncture as well as many other services provided by health care professionals Wherever you work as a coding specialist, there is an excellent chance you will be using this section. Discussion Activities 5. The administration of vaccinations and toxoids, as well as the various methods for administering medications (e.g., IM, IV, infusion, push, etc.). Identify each of the different types of codes and what each requires. [Learning Outcome: 11.1] Discuss the two essential parts of administering medication to a patient: the labor and supplies (syringe, alcohol swipe, etc.) + the serum within the syringe or IV bag. Then, add into the discussion the various methodologies for administrating and how the method will affect the code assignment.

6.

Review the cardiovascular services reported from the Medicine section. Cardiovascular monitoring services that can be provided in either the hospital or a cardiologist’s office. Discuss the components of the code descriptions and specify what the coder needs to know to determine the most accurate code. [Learning Outcome: 29.2] Instruct students to pay special attention to the guidelines provided directly above code 93224. Dissect these guidelines and have student analyze each part. 7.

Alternative medicine is growing in acceptance throughout the United States, especially by third-party payers. Divide the students into groups and have each create a presentation on what coders need to know about acupuncture, osteopathic treatments, and chiropractic treatments. [Learning Outcome: 29.11] See the Additional Resources section in this instructor’s manual for Internet resources that may assist students in their research. You might find a local professional in each of these areas to attend class as a guest speaker, and perhaps bring some redacted patient records. Additional Resources

Cardiac Catheterization (MedlinePlus): http://www.nlm.nih.gov/medlineplus/ency/article/003419.htm Cardiac Catheterization, Transesophageal Echocardiography (TEE), Electrophysiologic Tests, Thallium Stress Test (MPI or MUGA) (American Heart Association): http://www.heart.org/HEARTORG/Conditions/HeartAttack/SymptomsDiagnosisofHeartAtta ck/Invasive-Tests-and-Procedures_UCM_303931_Article.jsp Electrodiagnostic Medicine Listing of Sensory, Motor and Mixed Nerves in CPT book J

Appendix

Vascular Families chart in CPT book Appendix L American Chiropractic Association: http://www.acatoday.org/ American Massage Therapy Association: www.amtamassage.org/ American Occupational Therapy Association: http://www.aota.org/ American Osteopathic Association: www.osteopathic.org/ American Physical Therapy Association: http://www.apta.org//AM/Template.cfm?Section=Home Dialysis (MedicineNet): http://www.medicinenet.com/dialysis/article.htm Dialysis (MedlinePlus): http://www.nlm.nih.gov/medlineplus/dialysis.html International Chiropractors Association: http://www.chiropractic.org/?p=chiroinfo/main National Center for Complementary and Alternative Medicine: http://nccam.nih.gov/health/acupuncture/ Physical Therapy (NIH Clinical Center): http://www.cc.nih.gov/rmd/pt/index.html Rehabilitation (MedlinePlus): http://www.nlm.nih.gov/medlineplus/rehabilitation.html Treatment Methods for Kidney Failure: Peritoneal Dialysis (National Kidney and Urologic Diseases): http://kidney.niddk.nih.gov/kudiseases/pubs/peritoneal/ Vaccines & Immunizations (Centers for Disease Control and Prevention): http://www.cdc.gov/vaccines/hcp.htm

AAPC: www.aapc.com American Health Information Management Association: www.ahima.org American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org Updates for 2021 Reporting COVID-19 Immunizations New Vaccines, Toxoids have been created to specifically report the administration of the COVID-19 vaccines. These three codes differ by the quantity of the dosage. Remember: these codes only report the sera that was in the syringe. 91300 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use 91301 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use 91302 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19) vaccine, DNA, spike protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative-free, 5x1010 viral particles/0.5 mL dosage, for intramuscular use

As you are learning here, you will always need an additional code to report the actual administration services. These new codes are authorized for all COVID-19 vaccine sera approved by the FDA [Food and Drug Administration]. At this time, there are three sets of codes. Each set has one code for the first dose and a different code for the second dose. 0001A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose 0002A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose 0011A Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose 0012A Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose 0021A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative free, 5x1010 viral particles/0.5 mL dosage; first dose

0022A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative free, 5x1010 viral particles/0.5 mL dosage; second dose

Chapter 29 Review CPT Medicine Section Answer Key Let’s Check It! Terminology Answer: 1. E Infusion 2. A Ablation 3. J Push 4. B Catheter 5. H Optometrist 6. F Injection 7. G Ophthalmologist 8. C Duplex scan 9. I Otorhinolaryngology 10. D Immunization Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.05 Learning Objective: 29.06 Topic: Immunizations Topic: Injections and Infusions Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Blooms: Remember CAAHEP: V.C.10 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: B two codes: one for the administration and one for the drug. Feedback: Immunization of a patient includes two parts: the medication itself and the administration of the medication. Each part is coded separately. Learning Objective: 29.01 Topic: Immunizations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 2. Answer: B all appropriate services for each site. Feedback: The guidelines for coding injections and infusions provide further direction when coding these services: • When more than one infusion is provided into one IV site, report only the first service. • Should more than one IV site be used, report the appropriate services for each site. • Report different drugs or materials and that service separately. • Report infusion time as the actual time the fluid is provided. Learning Objective: 29.02 Topic: Injections and Infusions Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 3. Answer: 90837 Feedback: The correct code for Psychotherapy, 60-minutes with patient is 90837 90837: Index>Psychotherapy>individual Patient

Learning Objective: 29.03 Topic: Psychiatry, Psychotherapy, and Biofeedback Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute

4. Answer: D all of these. Feedback: The correct code for reporting dialysis service is determined by: the patient‘s age, where the services are provided, number of days treated and the level of physician services during the encounters.

Learning Objective: 29.04 Topic: Dialysis and Gastroenterology Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 5. Answer: B supply glasses and contact lenses. Feedback: Optometrist is a professional qualified to carry out eye examinations and to prescribe and supply eyeglasses and contact lenses. Learning Objective: 29.05 Topic: Ophthalmology and Otorhinolaryngologic Services Blooms: Remember CAAHEP: V.C.10 ABHES: 3.a CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 6 Answer: D 93931 Feedback: The correct code for a duplex scan of the left radial artery is 93931. The radial artery is the primary lateral artery of the forearm. 93931: Index>duplex scan>arterial studies>upper extremities Learning Objective: 29.06 Topic: Cardiovascular Services Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: A review of the pertinent patient examination. Feedback: Medication Therapy Management Services (MTMS) codes can be reported when all of the following has been documented • Review of the pertinent patient history. • Review of medication profile for prescription, non-prescription, and herbal supplements. • Specific recommendations for improving patient health outcomes.

• Recommendations to support the patient's treatment compliance. Learning Objective: 29.12 Topic: Other Services Provided Blooms: Analyze CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: C the number of regions treated. Feedback: Chiropractic manipulative treatment (CMT) codes 98940–98943 are measured by the number of regions treated during an encounter. Learning Objective: 29.11 Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: C 95822 Feedback: EEG; recording in coma or sleep only. 95822: Index>electroencephalography>coma. Learning Objective: 29.09 Topic: Neurology and Neuromuscular Procedures Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 10. Answer: D 97810, 97811, 97811 Feedback: Acupuncture is reported based on 15-minute increments of personal (face-toface) contact with the patient with the use of one or more needles. The time billed is only for face-to-face time, not the duration of the needle placement. 97810: Index>acupuncture>without electrical stimulation>initial 15 minutes.

97811: Index>acupuncture>without electrical stimulation>additional 15 minutes. 97811: Index>acupuncture>without electrical stimulation>additional 15 minutes. Learning Objective: 29.10 Topic: Physical Medicine and Rehabilitation Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Let’s Check It! Guidelines 1. Answer: Introduction, Medicine Feedback: In addition to the definitions and commonly used terms present in the Introduction, several other items unique to this section on Medicine are defined or identified here. Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: add-on, exempt Feedback: All add-on codes found in the CPT codebook are exempt from the multiple procedure concept. Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: identified, nomenclature Feedback: Add-on codes in the CPT codebook can be readily identified by specific descriptor nomenclature which includes phrases such as ―each additional‖ or ―(List separately in addition to primary procedure).‖

Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: ―separate procedure‖, integral Feedback: The codes designated as ―separate procedure‖ should not be reported in addition to the code for the total procedure or service of which it is considered an integral component. Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10

Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: independently, itself, 59, independent Feedback: When a procedure or service that is designated as a ―separate procedure‖ is carried out independently or considered to be unrelated or distinct from other procedures/services provided at the time, it may be reported by itself, or in addition to other procedures/services by appending modifier 59 to the specific ―separate procedure‖ code to indicate that the procedure is not considered to be a component to another procedure, but is a distinct, independent procedure. Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback

Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: 99070, supply Feedback: Supplies and materials over and above those usually included with the procedure(s) rendered are reported separately using code 99070 or specific supply code. Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: not, ―Unlisted Procedure‖, ―Special Report‖ Feedback: A service or procedure may be provided that is not listed in this edition of the CPT codebook. When reporting such a service, the appropriate ―Unlisted Procedure‖ code may be used to indicate the service, identifying it by ―Special Report.‖ Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: 99600

Feedback: Unlisted home visit service or procedure is reported with code 99600. Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: assessment Feedback: The psychotherapy services codes 90832-90838 include ongoing assessment and may include informants in the treatment process. Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09

Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: 16-minutes Feedback: Do not report psychotherapy of less than 16-minutes duration. Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology

Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: Medications can be given, or administered, to the patient in several different ways: percutaneous, intradermal, subcutaneous (SC), or intramuscular (IM) injections; intranasal (INH) or oral (ORAL); intra-arterial (IA) or intravenous (IV). The method of administration will help you find the correct administration codes 90460–90461 and 90471–90474. When more than one vaccine is provided on the same date, use the add-on codes for the administration of the additional injections. You will find that most of the codes are offered in sets: the first injection, administration, or hour and then the add-on code for each additional injection, administration, or hour. Feedback: Medications can be given, or administered, to the patient in several different ways: percutaneous, intradermal, subcutaneous (SC), or intramuscular (IM) injections; intranasal (INH) or oral (ORAL); intra-arterial (IA) or intravenous (IV). The method of administration will help you find the correct administration codes 90460–90461 and 90471–90474. When more than one vaccine is provided on the same date, use the add-on codes for the administration of the additional injections. You will find that most of the codes are offered in sets: the first injection, administration, or hour and then the add-on code for each additional injection, administration, or hour. Learning Objective: 29.01 Topic: Immunizations Blooms: Understand CAAHEP: I.P.4.d CAAHEP: I.P.5 CAAHEP: I.P.6 CAAHEP: I.P.7 CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 6.a ABHES: 6.b

ABHES: 7.d ABHES: 8.f CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: The infusion and injection codes include certain standard parts involved in administering liquids. Services included and therefore, not reported separately are: • The administration of a local anesthetic • The initiation of the IV • Accessing an indwelling IV, subcutaneous catheter, or port • Flushing the line at the completion of the infusion • The appropriate supplies: tubing, syringes, etc. Feedback: The infusion and injection codes include certain standard parts involved in administering liquids. Services included and therefore, not reported separately are: • The administration of a local anesthetic • The initiation of the IV • Accessing an indwelling IV, subcutaneous catheter, or port • Flushing the line at the completion of the infusion • The appropriate supplies: tubing, syringes, etc. Learning Objective: 29.02 Topic: Injections and Infusions Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: The categories of psychotherapy are:  Interactive complexity  Psychiatric diagnostic procedures  Psychotherapy  Psychotherapy for crisis  Other psychotherapy, services, or procedures Feedback: The categories of psychotherapy are:  Interactive complexity  Psychiatric diagnostic procedures

 Psychotherapy  Psychotherapy for crisis  Other psychotherapy, services, or procedures Learning Objective: 29.03 Topic: Psychiatry, Psychotherapy, and Biofeedback Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: Physician services provided during a dialysis month included in these codes are: • Determination of the dialysis cycle • Outpatient E/M of the dialysis visits • Telephone calls • Patient management • Face-to-face visit with the patient Feedback: Physician services provided during a dialysis month included in these codes are: • Determination of the dialysis cycle • Outpatient E/M of the dialysis visits • Telephone calls • Patient management • Face-to-face visit with the patient Learning Objective: 29.04 Topic: Dialysis and Gastroenterology Services Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: The codes available for reporting cardiac catheterization include the following: • The introduction of the catheter(s) • The positioning and repositioning of the catheter(s) • Recording of the intracardiac and intravascular pressure

• Obtaining blood samples for the measurement of blood gases, dilution curves, and/or cardiac output with or without electrode catheter placement • Final evaluation and report of the procedure Feedback: The codes available for reporting cardiac catheterization include the following: • The introduction of the catheter(s) • The positioning and repositioning of the catheter(s) • Recording of the intracardiac and intravascular pressure • Obtaining blood samples for the measurement of blood gases, dilution curves, and/or cardiac output with or without electrode catheter placement • Final evaluation and report of the procedure Learning Objective: 29.06 Topic: Cardiovascular Services Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Basics: 1. Answer: Psychotherapy, 90834 Feedback: Dr. Jameson performs a psychotherapy session with the patient, 45 minutes: Psychotherapy, 90834 90834: index>psychotherapy>individual patient/family member Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services

Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 2. Answer: TMS, 90867 Feedback: Dr. Graban completes a therapeutic repetitive transcranial magnetic stimulation (TMS) initial treatment: TMS, 90867 90867: index>psychiatric treatment>transcranial magnetic stimulation (TMS) Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 3. Answer: Biofeedback training, 90912 Feedback: Dr. Kantsiper performs biofeedback training, anorectal: Biofeedback training, 90912 90912: index>biofeedback training>anorectal Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 4. Answer: Electrogastrography, 91132 Feedback:

Dr. Abernethy completes a diagnostic transcutaneous electrogastrography: Electrogastrography, 91132 91132: index> electrogastrography Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 5. Answer: Fitting, 92072 Feedback: Dr. Shutter fits a contact lens for management of keratoconus initial fitting: Fitting, 92072 92072: index>fitting>contact lens Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06

Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 6. Answer: Nystagmus test, 92532 Feedback: Dr. Sanning completes a positional nystagmus test: Nystagmus test, 92532 92532: index>nystagmus test>positional Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services

Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 7. Answer: Tympanometry, 92550 Feedback: Dr. Foldings performs a tympanometry and reflex threshold measurements: Tympanometry, 92550 92550: index>tympanometry Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 8. Answer: Cardiac catheterization, 93451 Feedback: Dr. Edge completes a right heart catheterization including measurement of oxygen saturation and cardiac output: Cardiac catheterization, 93451 93451: index>cardiac catheterization>right heart Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 9. Answer: Duplex scan, 93925

Feedback: Dr. Pugh performs a duplex scan of lower extremity arteries bypass graft; complete bilateral study: Duplex scan, 93925 93925: index>duplex scan>arterial studies>lower extremity Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 10. Answer: Nitric oxide, 95012 Feedback: Dr. McKee completes nitric oxide expired gas determination: Nitric oxide, 95012 95012: index>nitric oxide>expired gas determination Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05

Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 11. Answer: Sleep study, 95800 Feedback: Dr. Middleton performs an unattended sleep study with simultaneous recording of heart rate, oxygen saturation, respiratory analysis and sleep time: Sleep study, 95800 95800: index>sleep study Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations

Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 12. Answer: Muscle testing, 95831 Feedback: Dr. Trezevant completes an ischemic limb exercise test with serial specimen(s) acquisition for muscle metabolite: Muscle testing, 95875 95875: index>muscle testing> ischemic limb Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation

Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 13. Answer: Chemotherapy, 96422 Feedback: Dr. Reese performs a chemotherapy administration, intra-arterial; infusion technique, 45 minutes: Chemotherapy, 96422 96422: index>chemotherapy>intra-arterial>infusion>45 minutes Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy

Est Time: 1-3 minutes 14. Answer: Perineum, 99170 Feedback: Dr. Kemper performs an anogenital (perineum) examination, magnified in childhood for suspected trauma: Perineum, 99170 99170: index>perineum>anogenital examination with magnification and image recording Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes 15. Answer: Prenatal testing, 99500 Feedback: Dr. Guinyard completes a home visit for prenatal monitoring and assessment including fetal heart rate and non-stress test: Prenatal testing, 99500 99500: index>prenatal testing>fetal monitoring>non-stress test, fetal

Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 1-3 minutes You Code It! Practice: 1. Answer: 94621 Feedback: 94621: Index> exercise test>cardiopulmonary Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08

Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: 96372, 96374-51 Feedback: 96372: Index>injection>subcutaneous 96374-51: Index>injection>intravenous push Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services

Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: 97813, 97814 Feedback: 97813: Index>acupuncture>with electrical stimulation>initial 15 minutes 97814: Index>acupuncture>with electrical stimulation>additional 15 minutes Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: 92620 Feedback: 92620: Index>audiologic function tests>central auditory function Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: 94640 Feedback:

94640: Index>inhalation treatment>pressurized or non-pressurized Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: 95004x11 Feedback: 95004x11: Index>allergy tests>skin tests>allergen extract>11 Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09

Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: 95120 Feedback: 95120: Index>allergen immunotherapy>allergenic extracts>injection and provision Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services

Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: 96409 Feedback: 96409: Index>chemotherapy>intravenous>push Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: 96365, 96361x3 Feedback: 96365: Index>infusion>intravenous>diagnostic/prophylactic/therapeutic>initial, up to 1 hour 96361x3: Index>infusion>hydration> each additional hour Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: 97124

Feedback: 97124: Index>massage>therapy Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: 93452, 99151 Feedback: 93452: index>cardiac catheterization>left heart>by transseptal puncture through intact septum>with>Ventriculography

99151: Index>sedation>moderate>younger than 5 years of age Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06

Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: 92602 Feedback: 92602: Index>cochlear device>programming Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services

Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: 92014 Feedback: 92014: Index>ophthalmology, diagnostic>eye exam>established patient>comprehensive Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: 93000 Feedback: 93000: Index>electrocardiography>evaluation Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: 95851

Feedback: 95851: Index>range of motion test>extremities or trunk>without hand Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application: Application 1: HAUPTON, NICHOLAS Answer: 96360, 94762-52 Feedback: 96360: CPT manual>index>Hydration>Intravenous>initial, 31 minutes to 1 hour 94762-52: CPT manual>index>Oximetry (noninvasive)>Blood O2 Saturation Determination>Ear or Pulse For the convenience of the instructor: 74283: CPT manual>index>Enema>Therapeutic>for Intussusception

Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: CARMICHAEL, ABIGAIL Answer: 98940, 98943-51, 97140x2 Feedback: 98940: CPT manual>index>Chiropractic Treatment>spinal>Extraspinal 98943-51: CPT manual>index>Chiropractic Treatment>spinal>Extraspinal 97140x2: CPT manual>index>Traction>Manual>each 15 minutes>2 (15 x 2 = 30 minutes) Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06

Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: TRAULER, CASIE Answer: 97035, 97110, 97140, 97124 Feedback: 97035: CPT manual>index>Physical Medicine/Therapy/Occupational Therapy>Modalities> Ultrasound 97110: CPT manual>index> Physical Medicine/Therapy/Occupational Therapy>Procedures> Therapeutic Exercises 97140: CPT manual>index> Physical Medicine/Therapy/Occupational Therapy>Manual Therapy 97124: CPT manual>index> Physical Medicine/Therapy/Occupational Therapy>Procedures> Massage Therapy Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08

Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: PASTNERNAC, ELSA Answer: 96105 Feedback: 96105: Index>aphasia testing>speech and language function Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services

Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: CRESSENA, FRANCIE Answer: 71046, 93000 Feedback: 71046: CPT manual>index>x-ray>chest> 2 views 93000: CPT manual>index>Electrocardiography>12 lead For the convenience of the instructor: 71046: CPT manual>index>X-Ray>Chest>2 views>frontal and lateral Learning Objective: 29.01 Learning Objective: 29.02 Learning Objective: 29.03 Learning Objective: 29.04 Learning Objective: 29.05 Learning Objective: 29.06 Learning Objective: 29.07 Learning Objective: 29.08 Learning Objective: 29.09 Learning Objective: 29.10 Learning Objective: 29.11 Learning Objective: 29.12 Topic: Immunizations Topic: Injections and Infusions Topic: Psychiatry, Psychotherapy, and Biofeedback Topic: Dialysis and Gastroenterology Services Topic: Ophthalmology and Otorhinolaryngologic Services Topic: Cardiovascular Services Topic: Pulmonary Topic: Allergy and Clinical Immunology Topic: Neurology and Neuromuscular Procedures Topic: Physical Medicine and Rehabilitation Topic: Acupuncture, Osteopathic, and Chiropractic Treatments

Topic: Other Services Provided Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 30: Physicians’ Services Capstone 2024 Compliant Learning Outcomes LO 30.1 Determine the correct procedure codes, using the CPT code set, for these case studies. Chapter Overview Patients come to a physician for help to feel better, or to maintain good health. You have learned that CPT codes are one of three code sets used to report WHAT the physician did for the patient during a specific encounter. Now, this chapter provides you with case studies so you can get some hands-on practice using CPT to report physician services. For each of the following case studies, read through the documentation, and determine: ∙ Which code or codes report WHAT the physician did for this patient. ∙ If any modifiers are necessary, and if so, which modifiers, and in what order. ∙ If more than one code is required, the sequence in which to report the codes. Remember, the notations, symbols, and Official Guidelines—both before each section as well as those in some subsections—are there to help you get it correct.

Additional Resources Grey’s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman’s Medical Dictionary: http://www.stedmans.com/ AAPC: http://www.aapc.com American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org

American Medical Association: http://www.ama-assn.org ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 30 Physicians’ Services Capstone Answer Key Case Study #1: Paul Hendricks Answer:

12032, 12004-59 Feedback: 12032: index>repair>skin>wound>intermediate 12004-59: index>repair>skin>wound>simple Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #2: Maria Curry Answer: 97161, 95851-50 Feedback: 97161: index>physical medicine/therapy/occupational therapy>evaluation> physical therapy 95851-50: index>range of motion test>extremities or trunk>without hand Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #3: Sabrina Barbara Answer: 59612 Feedback: 59612: index>delivery>See vaginal delivery>vaginal delivery>after previous cesarean delivery Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 3-5 minutes Case Study #4: Roger Forchetta Answer: 92002-57 Feedback: 92002-57: index>ophthalmology, diagnostic>eye exam>new patient Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #5: Camille Fields Answer: 95004x7, 95180x8 Feedback: 95004x7: index>allergy tests>skin test>allergen extract 95180x8: index>allergen immunotheraphy>rapid desensitization>8 hours Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #6: Belinda Pettaway Answer: 43753 Feedback: 43753: index>aspiration>stomach>therapeutic Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #7: Joseph Greeson Answer: 99212, 90375, J0696x4, 96372 Feedback: 99212: index>evaluation and management>office and other outpatient> established patient 90375: index>rabies>see vaccines>rabies J0696x4: HCPCS Level II code book>table of drugs and biologicals>rocephin>250mg> IV, IM 96372: index>injection>intramuscular Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #8: Monique Kennard Answer: 99213, 36415 Feedback: 99213: index>evaluation and management>office and other outpatient>established patient 36415: index>venipuncture>routine Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #9: Harrison Parker Answer:

99242, 70551, 72141, 36415, 80050 Feedback: 99242: index>evaluation and management>consultation 70551: index>magnetic resonance imaging (MRI)>diagnostic>brain 72141: index>magnetic resonance imaging (MRI)>diagnostic>spine>cervical 36415: index>venipuncture>routine 80050: index>blood tests>panels>general health Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #10: Tori Bensio Answer: 47562, 00790-P1-AA Feedback: 47562: index>cholecystectomy>laparoscopic 00790-P1-AA: index>anesthesia>abdomen>abdominal wall Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #11: Enid Reynolds Answer: 99282, 94010 Feedback: 99282: index>evaluation and management>emergency department visit 94010: index>spirometry Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #12: Arnold Titleman Answer: 45378, 99152, 99153, J2175, J2250x2 Feedback: 45378: index> colonoscopy>flexible>diagnostic 99152: index>sedation>moderate>initial 15 minutes 99153: index>sedation>moderate>additional 13 minutes J2175: HCPCS drug table>Demerol>50 mg J2250x2: HCPCS drug table>Versed>2 mg Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #13: Darlin Everstang Answer: 60210, 39402-51, 31622-51, 00320-P1 Feedback: 60210: index> isthmusectomy>thyroid gland 39402-51: index> mediastinoscopy>biopsy>mediastinal lymph node 31622-51: index> bronchoscopy>exploration 00320-P1: index>anesthesia>thyroid Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study # 14: Davida Prager Answer:

19101, 99152, J2250x2 Feedback: 19101: index> biopsy>breast 99152: index>sedation>moderate>initial 15 minutes J2250x2: HCPCS drug table>midazolam HCL>2 mg Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #15: Henry Systona Answer: 67412-RT, 68510-51-RT, 00140-P1 Feedback: 67412-RT: index>orbitotomy>without bone flap>with removal lesion 68510-51-RT: index>biopsy>lacrimal gland 00140-P1: index>anesthesia>eye Learning Objective: 30.01 Topic: Physicians‘ Services Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 31 HCPCS Level II 2024 Compliant

Learning Outcomes

LO 31.1 Abstract physician’s notes to identify the category of HCPCS Level II codes needed. LO 31.2 Employ the Alphabetic Index to find suggested HCPCS Level II codes. LO 31.3 Distinguish the types of services, products, and supplies reported with HCPCS Level II codes. LO 31.4 Follow the directions supplied by the notations and symbols. LO 31.5 Utilize the additional information provided by Appendices.

Chapter Outline Learning Outcomes Key Terms HCPCS Level II Categories The Alphabetic Index The Alphanumeric Listing Overview A0000–A0999 Transportation Services Including Ambulance A4000–A8004 Medical and Surgical Supplies A9000–A9999 Administrative, Miscellaneous, and Investigational B4000–B9999 Enteral and Parenteral Therapy C1000–C9999 CMS Hospital Outpatient Payment System D0000–D9999 Dental Procedures E0100–E8002 Durable Medical Equipment G0000–G9999 Procedures/Professional Services (Temporary) H0001–H9999 Behavioral Health And/Or Substance Treatment Services J0100–J8999 Drugs Other than Chemotherapy Drugs J9000-J9999 Chemotherapy Drugs K0000–K9999 Temporary Codes L0100–L4999 Orthotic Procedures L5000–L9999 Prosthetic Procedures M0000–M0301 Other Medical Services P0000–P9999 Pathology and Laboratory Q0000–Q9999 Temporary Codes Assigned By CMS R0000–R9999 Diagnostic Radiology Services S0000–S9999 Temporary National Codes Established by Private Payers T1000– T9999 Temporary National Codes Established By Medicaid V0000–V2999 Vision Services V5000–V5999 Hearing Services Symbols and Notations Symbols Notations Appendixes Chapter Summary Chapter 31 Review Let‘s Check It Terminology Let‘s Check It Concepts Let‘s Check It! Symbols and Notations Let‘s Check It! Rules and Regulations You Code It! Basics You Code It! Practice You Code It! Application

Chapter Overview There is another portion to the procedure coding system that professional coding specialists use to report services and treatments. HCPCS (pronounced ―hick-picks‖) is the acronym for Healthcare Common Procedure Coding System. Your students learned about the CPT codes used to report physician services and outpatient facility services. Remind them that they learned in Chapter 2 that:  HCPCS level I codes are referred to as CPT codes  HCPCS level II codes are referred to as HCPCS codes This part of this textbook will give them the opportunity to learn about HCPCS Level II codes (referred to as HCPCS codes). DMEPOS is a combination abbreviation that stands for



DME = Durable Medical Equipment

  

P = Prosthetics O = Orthotics S = Supplies

Transportation refers to moving a patient from one point to another, such as ambulance services. HCPCS level II codes and modifiers are listed in their own book, and are used to report services, procedures, and supplies that are not properly described in the CPT book. There are more than 5,000 HCPCS codes, each represented by five-characters: one letter followed by four numbers. Discussion Activities 8. Identify the types of services reported with HCPCS Level II codes. Include an example of these types of services and products. (Learning Outcome: 31.3) Discuss the purposes of having two different code sets: CPT and HCPCS Level II. 9.

Review the Table of Drugs in one of the HCPCS Level II Appendices. What information would a coder need from the patient record to report the medication(s) that were administered properly? (Learning Outcome: 31.5) Students should review the differences between brand/trade name, generic name, category, and dosages of drugs and medications reported from HCPCS Level II. Resources should be discussed to convert one version documented in the physician notes with another version that might connect to a specific code description.

Additional Resources Ambulance Services (CMS): https://www.cms.gov/center/ambulance.asp Durable Medical Equipment (CMS): https://www.cms.gov/center/dme.asp Home Health Agency (HHA) Center (CMS): https://www.cms.gov/center/hha.asp Skilled Nursing Facility Center (CMS): https://www.cms.gov/center/snf.asp AAPC: www.aapc.com American Health Information Management Association: www.ahima.org American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org Specialized Codes: COVID-19 Related Services [c head] The people of the United States have needed so many healthcare-related services due to COVID-19. An important part of medical coding is to enable the tracking of the use of medications and services. Therefore, beginning January 2021, new HCPCS Level II codes were established. Two new codes for the collection of specimens for testing to determine if the patient has been infected by COVID-19:  

G2023 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source G2024 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a SNF or by a laboratory on behalf of an HHA, any specimen source

Due to the specific location stated in the description of G2024, it is important to remember that this code should only be reported for those patients whose stays are not covered by Medicare. Skilled Nursing Facility (SNF) residents whose specimen has been collected during a Medicare-covered stay will have these, and other lab services and tests, covered under Part A’s SNF benefit. [FYI: HHA = Home Health Agency] The work provided by the laboratory processing these specimens will also have specific codes to report, depending upon the details of the testing.  

U0001 CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel U0002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC







U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS2020-01-R U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R U0005 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, CDC or non-CDC, making use of high throughput technologies completed within 2 calendar days from date of specimen collection (list separately in addition to either HCPCCS code U0003 or U0004) as described by CMS-2020-01-R2

Four new codes for drugs used to treat patients with a confirmed diagnosis of COVID-19, one for an injection and another for infusion:  

Q0239 Injection, bamlanivimab, 700 mg Q0243 Injection, casirivimab and imdevimab, 2400 mg

It should be noted that, according to CMS, those providers who receive this drug for free should not report either code Q0239 or Q0243. If the administration of this drug is being tracked for purposes, other than reimbursement, the code can be reported with a price of Zero or $0.01 (one cent).  

M0239 Intravenous infusion, bamlanivimab-xxxx, includes infusion and post- administration monitoring M0243 Intravenous infusion, casirivimab and imdevimab includes infusion and post-administration monitoring

Chapter 31 Review Answer Key

Let’s Check It! Terminology Answer: 1. B Basic Life Support (BLS) 2. E Durable Medical Equipment Regional Carrier (DMERC) 3. I Parenteral 4. G Not Otherwise Specified (NOS) 5. H Orthotic 6. A Advanced Life Support (ALS) 7. D Durable Medical Equipment (DME) 8. F Enteral 9. J Prosthetic 10. C Chelation Therapy 11. K Specialty Care Transport Learning Objective: 31.01 Learning Objective: 31.03 Learning Objective: 31.04 Topic: HCPCS Level II Categories

Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: D a service not covered under the skilled nursing facility payment system. Feedback: A circle with a slash through it, in the HCPCS Level II book, identifies a code that is not covered under the skilled nursing facility (SNF) prospective payment system (PPS). Learning Objective: 31.04 Topic: Symbols and Notations Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 2. Answer: A includes a quantity measurement. Feedback: A check mark inside a square box marks a code description that identifies a specific quantity of material or supply. It is a reminder for you to check the detail in the notes and report the code not only for the item it represents but for the amount as well. Learning Objective: 31.04 Topic: Symbols and Notations Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute

3. Answer: B drugs administered by a health care professional. Feedback: J0120–J9999 Drugs Administered Other than Oral Method ~ As the title so clearly states, the Drugs Administered Other than Oral Method category provides you with codes to identify drugs that are given to the patient by a health care professional in any way other than by mouth. This includes chemotherapy drugs, immunosuppressive drugs, inhalation solutions, and other miscellaneous drugs and solutions. Learning Objective: 31.03 Topic: The Alphanumeric Listing Overview Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 4. Answer: C anesthesia administered by an anesthesiologist. Feedback: HCPCS Level II codes cover specific aspects of health care services, including: • Durable medical equipment (e.g., a wheelchair or a humidifier) • Pharmaceuticals administered by a health care provider (e.g., a saline solution or a chemotherapy drug) • Medical supplies provided for the patient‘s own use (e.g., an eye patch or gradient compression stockings) • Dental services (e.g., all services provided by a dental professional). • Transportation services (e.g., ambulance services) • Vision and hearing services (e.g., trifocal spectacles or a hearing screening) • Orthotic and prosthetic procedures (e.g., scoliosis braces or postsurgical fitting) Learning Objective: 31.01 Topic: HCPCS Level II Categories Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 5. Answer: B durable medical equipment.

Feedback: DME stands for durable medical equipment. Learning Objective: 31.03 Topic: The Alphanumeric Listing Overview Blooms: Remember CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 6. Answer: B one letter followed by four numbers. Feedback: HCPCS Level II codes and modifiers are listed in their own book and are used to report a service, procedure, and supplies that are not properly described in the CPT book. There are almost 5,000 HCPCS codes, each represented by five characters: one letter followed by four numbers. Learning Objective: 31.01 Topic: HCPCS Level II Categories Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 7. Answer: D Healthcare Common Procedure Coding System. Feedback: HCPCS (pronounced ―hick-picks‖) is the acronym for Healthcare Common Procedure Coding System. Learning Objective: 31.01 Topic: HCPCS Level II Categories Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 8. Answer: B HCPCS Level II code.

Feedback: D1110 is an example of a HCPCS Level II code. D1110 Prophylaxisadult Learning Objective: 31.03 Topic: The Alphanumeric Listing Overview Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: B American Dental Association. Feedback: D0000–D9999 Dental Procedures~ The Dental Procedures category is the Current Dental Terminology (CDT) code set, copyrighted by the American Dental Association. The codes are used to report dental services. Learning Objective: 31.03 Topic: The Alphanumeric Listing Overview Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: D All of these. Feedback: The Alphabetic Index lists the Level II code descriptions in alphabetic order from A to Z. After abstracting the key terms from the provider's notes, you can look up key words in the index by using the following:  Brand name of the drug  Generic name of the drug  Medical supply item  Orthotic  Prosthetic  Service  Surgical supply Learning Objective: 31.02 Topic: The Alphabetic Index Blooms: Understand CAAHEP: IX.C.1

CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 11. Answer: B used to identify DME provided to a patient. Feedback: E0100–E9999 Durable Medical Equipment - The E codes are used to identify certain pieces of durable medical equipment (DME) provided to a patient. Learning Objective: 31.03 Topic: The Alphanumeric Listing Overview Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 12. Answer: C a three-prong cane. Feedback: E0100–E9999 Durable Medical Equipment - The E codes are used to identify certain pieces of durable medical equipment (DME) provided to a patient. Examples: E0105 Cane, quad, or 3-prong, includes canes of all materials, adjustable or fixed, with tips E0156 Seat attachment, walker E0242 Bathtub rail, floor base Learning Objective: 31.03 Topic: The Alphanumeric Listing Overview Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 13. Answer: D the code is no longer available to represent the service or item.

Feedback: A deleted code is represented with a line through the center of the code and its description means that the code has been deleted and may no longer be used. Learning Objective: 31.04 Topic: Symbols and Notations Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 14. Answer: A H0001-H2037. Feedback: H0001–H2037 Alcohol and Drug Abuse Treatment Services - When alcohol and drug treatment, as well as some other mental health services, are provided, some state Medicaid agencies will have you use codes from the Alcohol and Drug Abuse Treatment Services category. Learning Objective: 31.03 Topic: The Alphanumeric Listing Overview Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 15. Answer: C the service is limited to a specific age group. Feedback: The ―A‖ symbol highlights the fact that a code is used only for procedures, services, and equipment that are performed or used on a patient of a certain age group. Read the code description carefully to ensure the age limitation of the code matches the patient. Learning Objective: 31.04 Topic: Symbols and Notations Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium

Est Time: 0-1 minute Let’s Check It! Symbols and Notations Part I Answer: 1. G 2. A 3. B 4. J 5. C 6. I 7. F 8. E 9. H 10. D Feedback: 1. G 2. A 3. B 4. J 5. C 6. I 7. F 8. E 9. H 10. D Learning Objective: 31.04 Topic: Symbols and Notations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Part II Answer: 1. B See also code . . . 2. E See code(s) 3. D Report in addition to code . . . 4. A Always report concurrent to the xxx procedure

5. C Clarifications of coverage 6. F Determine if an alternative HCPCS Level II or a CPT code better describes . . 7. K Code with caution 8. I Do not use this code to report . . . 9. G Use this code for . . . 10. J Medicare covers . . . 11. H Pertinent documentation to evaluate medical appropriateness should be . . Feedback: B See also code . . . 2. E See code(s) 3. D Report in addition to code . . . 4. A Always report concurrent to the xxx procedure 5. C Clarifications of coverage 6. F Determine if an alternative HCPCS Level II or a CPT code better describes . . 7. K Code with caution 8. I Do not use this code to report . . . 9. G Use this code for . . . 10. J Medicare covers . . . 11. H Pertinent documentation to evaluate medical appropriateness should be . . Learning Objective: 31.04 Topic: Symbols and Notations Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Let’s Check It! Rules and Regulations: 1. Answer: HCPCS Level II codes cover specific aspects of health care services, including: • Durable medical equipment (e.g., a wheelchair or a humidifier) • Pharmaceuticals administered by a health care provider (e.g., a saline solution or a chemotherapy drug) • Medical supplies provided for the patient‘s own use (e.g., an eye patch or gradient compression stockings) • Dental services (e.g., all services provided by a dental professional). • Transportation services (e.g., ambulance services) • Vision and hearing services (e.g., trifocal spectacles or a hearing screening)

• Orthotic and prosthetic procedures (e.g., scoliosis braces or postsurgical fitting) Feedback: HCPCS Level II codes cover specific aspects of health care services, including: • Durable medical equipment (e.g., a wheelchair or a humidifier) • Pharmaceuticals administered by a health care provider (e.g., a saline solution or a chemotherapy drug) • Medical supplies provided for the patient‘s own use (e.g., an eye patch or gradient compression stockings) • Dental services (e.g., all services provided by a dental professional). • Transportation services (e.g., ambulance services) • Vision and hearing services (e.g., trifocal spectacles or a hearing screening) • Orthotic and prosthetic procedures (e.g., scoliosis braces or postsurgical fitting) Learning Objective: 31.01 Topic: HCPCS Level II Categories Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: Not all insurance carriers accept HCPCS Level II codes, but Medicare and Medicaid want you to use them. It is your responsibility as a coding specialist to find out whether each third-party payer with which your facility works accepts HCPCS Level II codes. If not, you have to ask for the payer‘s policies on reporting the services and supplies covered by HCPCS Level II. Feedback: Not all insurance carriers accept HCPCS Level II codes, but Medicare and Medicaid want you to use them. It is your responsibility as a coding specialist to find out whether each third-party payer with which your facility works accepts HCPCS Level II codes. If not, you have to ask for the payer‘s policies on reporting the services and supplies covered by HCPCS Level II. Learning Objective: 31.01 Topic: HCPCS Level II Categories Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium

Est Time: 3-5 minutes 3. Answer: After abstracting the key terms from the provider‘s notes, you can look up key words in the index by using the following: • Brand name of the drug. • Generic name of the drug. • Medical supply item. • Orthotic. • Prosthetic. • Service. • Surgical supply Feedback: After abstracting the key terms from the provider‘s notes, you can look up key words in the index by using the following: • Brand name of the drug. • Generic name of the drug. • Medical supply item. • Orthotic. • Prosthetic. • Service. • Surgical supply Learning Objective: 31.02 Topic: The Alphabetic Index Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: G0000–G9999 Procedures/Professional Services (Temporary) - Codes from this section are used to report services and procedures that do not have an accurate code description in the main portion of the CPT book. Feedback: G0000–G9999 Procedures/Professional Services (Temporary) - Codes from this section are used to report services and procedures that do not have an accurate code description in the main portion of the CPT book. Learning Objective: 31.03 Topic: The Alphanumeric Listing Overview Blooms: Apply CAAHEP: IX.C.1

CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: The notation Use this code for provides you with alternative names, brand names, and other terms that are also represented by the code‘s description. Feedback: The notation Use this code for provides you with alternative names, brand names, and other terms that are also represented by the code‘s description. Learning Objective: 31.04 Topic: Symbols and Notations Blooms: Understand CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Basics: 1. Answer: Strip, A4253 Feedback: A bottle of 50 blood glucose reagent strips: Strip, A4253 A4253: Index>strip>blood glucose test Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 2. Answer: Water, A7018 Feedback: Johannsen Health Care delivered 1000 mL of distilled water for use with nebulizer: Water, A7018 A7018: Index>water>distilled for nebulizer>1000mL Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 3. Answer: Incontinence, T4533 Feedback: Youth-sized disposable incontinence brief, one: Incontinence, T4533 T4533: Index>incontinence>youth>brief>each Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 4. Answer: Blood, A4750 Feedback: Arterial blood tubing: Blood, A4750 A4750: Index>blood>tubing Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 5. Answer: Neonatal, A0225 Feedback: Neonate ambulance transport, one-way, base rate: Neonatal, A0225 A0225: Index>neonatal transport>ambulance>base rate>one-way Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index

Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 6. Answer: Ambulance, A0422 Feedback: Ambulance ride with oxygen administered along with other advanced life support (ALS) services: Ambulance, A0422 A0422: Index>ambulance>oxygen Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 7. Answer: Transportation, T2005 Feedback: Non-emergency transportation by stretcher van: Transportation, T2005 T2005: Index>transportation>non-emergency>stretcher van Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03

Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 8. Answer: Chloroquine, J0390 Feedback: A 200-mg injection IM of chloroquine hydrochloride: Chloroquine, J0390 J0390: Index>drug table>chloroquine HCI>up to 250 mg>IM Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 9. Answer: Codeine phosphate, J0745 Feedback: An injection SC of 30 mg of codeine phosphate: Codeine phosphate, J0745 J0745: Index>drug table>codeine phosphate>per 30 mg>SC

Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 10. Answer: Fosphenytoin, Q2009 Feedback: Dr. Longwell ordered fosphenytoin, with an initial dose of 50 mg: Fosphenytoin, Q2009 Q2009: Index>drug table>Fosphenytoin >50 mg Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 11.

Answer: Lepirudin, J1945 Feedback: A 25-mg injection of lepirudin: Lepirudin, J1945 J1945: Index>drug table>lepirudin>50 mg Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 12. Answer: Walker, E0156 Feedback: A seat attachment for a Starke‘s walker: Walker, E0156 E0156: Index>walker>attachment Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy

Est Time: 3-5 minutes 13. Answer: Protector, E0191 Feedback: One heel protector: Protector, E0191 E0191: Index>protector>heel Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 14. Answer: Ventilator, E0466 Feedback: A portable non-invasive ventilator: Ventilator, E0466 E0466: Index>ventilator>used with non-invasive interface Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes 15. Answer: Prostate, G0103 Feedback: Prostate cancer screening, antigen test: Prostate, G0103 G0103: index>prostate, cancer, screening Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 3-5 minutes You Code It! Practice: 1. Answer: E0570 Feedback: E0570: Index>nebulizer Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: E1630 Feedback: E1630: Index>reciprocating>peritoneal dialysis system Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: G0257 Feedback: G0257: Index>dialysis>unscheduled treatment Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations

Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: J3230 Feedback: J3230: Index>drug table>Thorazine>up to 50 mg Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: J7513x4 Feedback: J7513x4: Index>drug table>Zenapax>IV>4 (25 mg x 4= 100) Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview

Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: J7517 Feedback: J7517: Index>drug table>CellCept>250 mg>oral Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: B4150x5 Feedback: B4150x5: Index>enteral>formulae>5 (100 x 5 = 500 calories) Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index

Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: D6065 Feedback: D6065: Index>dental>implants Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: D8703 Feedback: D8703: Index>dental>orthodontics Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories

Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: E0160 Feedback: E0160: Index>bath>aid Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: E0290 Feedback: E0290: Index>hospital>bed Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05

Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: E0189 Feedback: E0189: Index>pad>sheepskin Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: D5110, D5120 Feedback: D5110: Index>dentures>maxillary D5120: Index>dentures>mandibular Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03

Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: E0245 Feedback: E0245: Index>bathtub>stool Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: E1172 Feedback: E1172: Index>wheelchair>amputee Learning Objective: 31.01 Learning Objective: 31.02

Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application: Application 1: ADDLER, ANNETTE Answer: B4082 Feedback: B4082: Index>tube/tubing>nasogastric>without stylet Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: CARLYLE, JOY Answer:

E0890, E0273 Feedback: E0890: Index>traction>pelvic>attached to footboard E0273: Index>bed>accessories>bed board Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: BALMORAL, MARK Answer: J9060 x 2 Feedback: J9060 x 2: Index>drug table>cisplatin, powder or solution>per 10 mg>IV>2 (10 mg x 2 = 20 mg) Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 3-5 minutes Application 4: CUTTER, WILIMENA Answer: A0427-QM-NH, A0398, A0390x5 Feedback: A0427-QM-NH: Index>advanced>life support>ALS1-emergency Ambulance modifier N from Skilled Nursing Facility (SNF) Ambulance modifier H to hospital A0398: Index>disposable>supplies>ambulance>ALS routine disposable supplies A0390x5: Index>ALS mileage>per mile>5 (4.5 rounds to 5 miles) Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: VANCE, TOMIKA Answer: G0105-74 Feedback: G0105-74: HCPCS manual>index>Screening>Colorectal>Cancer>Individuals at high risk For convenience of instructor 99149: CPT manual>index>Sedation>Moderate>5 years old and older Learning Objective: 31.01 Learning Objective: 31.02 Learning Objective: 31.03 Learning Objective: 31.04 Learning Objective: 31.05 Topic: HCPCS Level II Categories

Topic: The Alphabetic Index Topic: The Alphanumeric Listing Overview Topic: Symbols and Notations Topic: Appendices Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 32: DMEPOS and Transportation Capstone 2024 Compliant Learning Outcomes LO 32.1 Determine the correct codes for these case studies using the HCPCS Level II code set.

Chapter Overview The health care team extends beyond the physician’s office or hospital. Home care services are on the increase as a greater number of patients prefer care in their residences, whenever possible. The provision of these services enables patients greater comfort and lowers costs, especially for those with chronic conditions. In addition, transportation of patients should be recorded and reported for reimbursement purposes, as well as the provision of orthotics and prosthetics. And, as your students learned in previous chapters about CPT coding, the provision of medication (drugs) by a health care professional also must be recorded and reimbursed. For each of the following case studies, direct your students to read through the documentation and determine:



What medical supply, equipment, or other item or service was provided to this patient. Do not code the procedure.



Whether any modifiers are necessary, and, if so, which modifiers and in what order.



Whether more than one code is required, and, if so, the sequence in which to report the codes.

Remind them to read carefully and completely.

Additional Resources Grey’s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman’s Medical Dictionary: http://www.stedmans.com/ AAPC: http://www.aapc.com

American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org

American Medical Association: http://www.ama-assn.org ICD-10-PCS: http://www.cdc.gov/nchs/icd/icd10cm.htm Chapter 32 Answer Key

You Code It! DMEPOS and Transportation Capstone Chapter 32 HCPCS Level II Capstone Case Study #1: Rhonda Syncowski Answer: J7641, E0570, E0431, E0443 Feedback: J7641: HCPCS Table of Drugs and Biologicals>Flunisolide, compounded, unit dose> 1 MG INH E0570: HCPCS Alphabetic Index>nebulizer>portable E0431: HCPCS Alphabetic Index>Oxygen>supplies and equipment E0443: HCPCS Alphabetic Index>Oxygen>supplies and equipment Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #2: Ryan McNaulty Answer: J2710 Feedback: J2710: HCPCS Table of Drugs and Biologicals>Neostigmine methylsulfate, up to 0.5 mg> IV/IM Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #3: Nadiya Longstep Answer: A0427-RH Feedback: A0427-RH: HCPCS Alphabetic Index>Ambulance Origin: R – Residence Destination: H - Hospital Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #4: Sonia Grasso Answer: L1000 Feedback: L1000: HCPCS Alphabetic Index>CTLSO Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #5: Daniel Bishop Answer: E0840 Feedback: E0840: HCPCS Alphabetic Index>Traction equipment Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies

Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #6: Malik Humiston Answer: E0117x2 Feedback: E0117x2: HCPCS Alphabetic Index>Crutches>underarm Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #7: Zivah Mastriani Answer: A9275 Feedback: A9275: HCPCS Alphabetic Index>glucose testing >disposable monitor Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #8: Victor Jeffries Answer: E0197

Feedback: E0197: HCPCS Alphabetic Index> Air pressure pad/mattress Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #9: Anna Cheng Answer: B4087 Feedback: B4087: HCPCS Alphabetic Index>Tube/tubing> Gastrostomy Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #10: Cecil Denoso Answer: J1630x3 Feedback: J1630x3: HCPCS Table of Drugs and Biologicals>Haldol>5mg>IM, IV Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

Case Study #11: Courtnee Callahan Answer: E0720 Feedback: E0720: HCPCS Level II Alphabetic Index>TENS>Neuro-Pulse Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #12: Arthur Paige Answer: E0855 Feedback: E0855: HCPCS Level II Alphabetic Index> Traction equipment>cervical equipment>not requiring frame Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #13: Willetta Freedman Answer: E1801 Feedback: E1801: HCPCS Level II Alphabetic Index>orthotic devices>elbow Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study # 14: Gary Elliott Answer: E0601, A7035 Feedback: E0601: HCPCS Level II Alphabetic Index> CPAP A7035: HCPCS Level II Alphabetic Index> CPAP>headgear Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Case Study #15: Paula Barkin Answer: G0153x2, E2504 Feedback: G0153x2: HCPCS Level II Alphabetic Index>hospice and/or home health services>speech and language

E2504: HCPCS Level II Alphabetic Index>speech generating device>digitized speech, more than 20 minutes

Learning Objective: 32.01 Topic: DMEPOS and Transportation Case Studies Blooms: Apply CAAHEP: IX.C.1 CAAHEP: IX.C.3 CAAHEP: IX.P.1 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 33 Introduction to ICD-10-PCS 2024 Compliant Learning Outcomes

LO 33.1 Explain the purpose of ICD-10-PCS codes. LO 33.2 Identify the structure of ICD-10-PCS codes. LO 33.3 Recognize the proper ways to use the Alphabetic Index and Tables in ICD-10-PCS. LO 33.4 Discern the general conventions for using ICD-10-PCS. LO 33.5 Determine the principal ICD-10-PCS code and proper sequencing for multiple procedure codes. Chapter Outline Learning Outcomes Key Terms The Purpose of ICD-10-PCS The Structure of ICD-10-PCS Codes Seven Characters Section (First Character) Body System (Second Character) Root Operation (Third Character) Body Part (Fourth Character) Approach (Fifth Character) Device (Sixth Character) Qualifier (Seventh Character) Placeholder Characters The ICD-10-PCS Book The Alphabetic Index The Tables Appendices ICD-10-PCS General Conventions Selection of Principal Procedure Chapter Summary Chapter 33 Review Let‘s Check It! Terminology Let‘s Check It! Concepts Let‘s Check It! Rules and Regulations You Code It! Application Chapter Overview ICD-10-PCS (International Classification of Diseases, 10th revision, Procedure Coding System) officially replaced ICD-9-CM Volume 3 procedure codes beginning October 1, 2015. At the same time, ICD-9-CM Volumes 1 and 2 (diagnosis codes) are replaced by ICD-10-CM—a more precise and efficient diagnostic coding system. ICD-10-PCS provides more specificity for various procedures, as well as making it easier to incorporate new procedures as they are developed and accepted by health care professionals. This chapter identifies the distinct benefits of ICD-10-PCS. Then, step-

by-step, the chapter differentiates the way the codes look and are constructed. The notations and explanations, exclusive to ICD-10-PCS, are all reviewed. Examples are provided to illustrate the concepts and elements, giving you an idea of what to expect, and to help you establish a comfort level so that you are not apprehensive about the new system. It‘s going to be great! Additional information about ICD-10-PCS can be found at: https://www.cms.gov/medicare/icd-10/2022-icd-10-pcs

Discussion Activities 1. Explain, in your own words, the purpose of the ICD-10-PCS code set. What types of health care facilities use these codes to report procedures and services? (Learning Outcome: 33.1) This exercise gives students the opportunity to understand that ICD-10-PCS codes are used to report inpatient procedures and services only. 2. Choose one of the General Conventions or Guidelines for using ICD-10-PCS and explain it in your own words. Create a scenario that would document a procedure or service that would be reported by ICD-10-PCS that would illustrate that convention or guideline. (Learning Outcome: 33.4). This exercise is designed to give students additional motivation to integrate the reading and use of the Conventions and Guidelines to code accurate. Additional Resources 2018 ICD-10-PCS and GEMs (CMS): https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-PCS-andGEMs.html A Brief History of ICD-10-PCS (AHIMA): http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_0 04938.hcsp?dDocName=bok3_004938 AAPC: www.aapc.com American Health Information Management Association: www.ahima.org American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org Chapter 33 Review Answer Key Let’s Check It! Terminology Answer: 1. E Device 2. G Root Operation Term 3. C Body Part 4. F Qualifier 5. D Body System 6. A Approach

7. B Axis of Classification Learning Objective: 33.03 Learning Objective: 33.04 Topic: The ICD-10-PCS Book Topic: ICD-10-PCS General Conventions Blooms: Remember CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: B Procedure Coding System. Feedback: ICD-10-PCS: International Classification of Diseases, 10th revision, Procedure Coding System Learning Objective: 33.01 Topic: The Purpose of ICD-10-PCS Blooms: Remember CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: A root operation terms. Feedback: The alphabetic index‘s entries are primarily sorted by root operation terms. A root operation term identifies the specific service or type of treatment that is the basis of the entire procedure. Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 3.

Answer: C seven characters. Feedback: Every ICD-10-PCS code is made up of seven (7) alphanumeric characters, and each character position has its own specific meaning -- a specific piece of information relating to the procedure, service, or treatment provided. You must read carefully, because each section has its own particular use for the character. As always, in coding, you can never assume! Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 4. Answer: D letters and numbers. Feedback: ICD-10-PCS codes have seven characters and are alphanumeric (both letters and numbers). ICD-10-PCS codes may include any letter of the alphabet except the letters O and I. This is done to avoid any confusion between the letter O and the number 0, as well as any mix-up between the letter I and the number 1. Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 5. Answer: A bypass. Feedback: Bypass is an example of a root operation term. The third character in the ICD-10-PCS code reports the root operation—the central aspect of the procedure or service being provided. Some examples of root operation terms—Medical & Surgical Section: 0 Alteration J Inspection 1 Bypass K Map 2 Change L Occlusion 3 Control M Reattachment 4 Creation N Release 5 Destruction P Removal

6 Detachment Q Repair 7 Dilation R Replacement 8 Division S Reposition 9 Drainage T Resection B Excision U Supplement C Extirpation V Restriction D Extraction W Revision F Fragmentation X Transfer G Fusion Y Transplantation H Insertion Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 6. Answer: D body system. Feedback: The digestive system is an example of a body system. The second character of the code reports the body system upon which the procedure, service, or treatment was performed. Examples of Medical and Surgical Section Body Systems: 0 Central nervous system J Subcutaneous tissue and fascia 1 Peripheral nervous system K Muscles 2 Heart and great vessels L Tendons 3 Upper arteries M Bursae and ligaments 4 Lower arteries N Head and facial bones 5 Upper veins P Upper bones 6 Lower veins Q Lower bones 7 Lymphatic and hemic systems R Upper joints 8 Eye S Lower joints 9 Ear, Nose, Sinus T Urinary System B Respiratory system U Female reproductive system C Mouth and throat V Male reproductive system D Gastrointestinal system W Anatomical regions, general F Hepatobiliary system and pancreas X Anatomical regions, upper extremities G Endocrine system Y Anatomical regions, lower extremities H Skin and breast Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 7. Answer: B numbers 0-9, then letters B-H and X. Feedback: The first character in the seven-character sequence identifies the section in which the procedure is listed. The sections of ICD-10-PCS are identified by numbers 0-9 and letters B-H and X. The 17 Sections of ICD-10-PCS are: 0 Medical and Surgical 1 Obstetrics 2 Placement 3 Administration 4 Measurement and Monitoring 5 Extracorporeal Assistance and Performance Audiology 6 Extracorporeal Therapies 7 Osteopathic

8 Other Procedures 9 Chiropractic B Imaging C Nuclear Medicine D Radiation Oncology F Physical Rehabilitation and Diagnostic G Mental Health H Substance Abuse Treatment X New Techniology

Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 8. Answer: C the letter Z. Feedback: The letter Z means ―not applicable‖ or ―none.‖ The Z placeholder will be used most often as the seventh character; however, it can be used in any of the seven character positions, when needed. It can also be used in multiple positions in one code. Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 9. Answer: A open. Feedback: The term approach as reported by the fifth character reports the technique or methodology used during the procedure, such as open or laparoscopic, percutaneous, via natural or artificial opening, external, or anterior. Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: C pacemaker. Feedback: Some of the sections use the sixth character to identify a device used in the procedure. To some, this term may conjure up pictures of hard, metal equipment. However, in ICD-10-PCS, the term device is used in a more general sense to mean any item that will remain in or with the body after the procedure is complete. So it might mean equipment, such as a pacemaker, or it may report the use of a graft. Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 11. Answer: B Section 1 Obstetrics. Feedback: The section that would cover a cesarean section would be Section1, Obstetrics. The first character in the seven-character sequence identifies the section in which the procedure is listed. The sections of ICD-10-PCS are identified by numbers 0-9 and letters B-H and X.

The 17 Sections of ICD-10-PCS: 0 Medical and Surgical 8 Other Procedures 1 Obstetrics 9 Chiropractic 2 Placement B Imaging 3 Administration C Nuclear Medicine 4 Measurement and Monitoring D Radiation Oncology 5 Extracorporeal Assistance and Performance F Physical Rehabilitation and Diagnostic Audiology 6 Extracorporeal Therapies G Mental Health 7 Osteopathic H Substance Abuse Treatment X New Technology Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 12. Answer: D Section 9 Chiropractic. Feedback: The section that would cover a chiropractic manipulation would be Section 9 Chiropractic. The first character in the seven-character sequence identifies the section in which the procedure is listed. The sections of ICD-10-PCS are identified by numbers 0-9 and letters B-H and X. The 17 Sections of ICD-10-PCS: 0 Medical and Surgical 8 Other Procedures 1 Obstetrics 9 Chiropractic 2 Placement B Imaging 3 Administration C Nuclear Medicine 4 Measurement and Monitoring D Radiation Oncology 5 Extracorporeal Assistance and Performance F Physical Rehabilitation and Diagnostic Audiology 6 Extracorporeal Therapies G Mental Health 7 Osteopathic H Substance Abuse Treatment

X New Technology Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 13. Answer: C 4. Feedback: Some of the sections will use the sixth character to identify a device used in the procedure. In ICD-10-PCS, the term device is used in a general sense to mean any item that will remain in or with the body after the procedure is complete. In code 2W22X4Z, ―4‖ presents the device. Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 14. Answer: B X Feedback: The term approach as reported by the fifth character reports the technique or methodology used during the procedure, such as open or laparoscopic. In code 3E00X3Z, ―X‖ represents the approach. Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 15. Answer: A 1

Feedback: The third character in the ICD-10-PCS code reports the root operation—the central aspect of the procedure or service being provided. In code 3E1S38Z, ―1‖ represents the root operation. Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 16. Answer: A 2 Feedback: The first character in the seven-character sequence identifies the section in which the procedure is listed. In code 2W10X7Z, ―2‖ represents the section. Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 17. Answer: D M Feedback: The seventh character in the seven-character sequence identities the qualifier. In code 3E0Y70M, ―M‖ represents the qualifier. Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 18. Answer: C three, four. Feedback:

The Alphabetic Index will usually give you only the first three or four characters of the seven-character procedure code. You then must go to the tables to find the additional characters. You won‘t have to be reminded to never code from the Alphabetic Index with ICD-10-PCS. Most of the time, you won‘t be able to code from the Alphabetic Index alone anymore! Learning Objective: 33.03 Topic: The ICD-10-PCS Book Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 19. Answer: D A9. Feedback: A1. ICD-10-PCS codes are composed of seven characters. Each character is an axis of classification that specifies information about the procedure performed. A2. One of 34 possible values can be assigned to each axis of classification in the seven-character code: they are the numbers 0 through 9 and the letters of the alphabet (except I and O because they are easily confused with the numbers 1 and 0). A3. The valid values for an axis of classification can be added to as needed. A4. As with words in their context, the meaning of any single value is a combination of its axis of classification and any preceding values on which it may be dependent. A5. As the system is expanded to become increasingly detailed, over time more values will depend on preceding values for their meaning. A6. The purpose of the Alphabetic Index is to locate the appropriate table that contains all information necessary to construct a procedure code. A7. It is not required to consult the Index first before proceeding to the Tables to complete the code. A8. All seven characters must be specified to be a valid code. A9. Within a PCS Table, valid codes include all combinations of choices in characters 4 through 7 contained in the same row of the table. A10. ―And,‖ when used in a code description, means ―and/or.‖ A11. Many of the terms used to construct PCS codes are defined within the system. Learning Objective: 33.04 Topic: ICD-10-PCS General Conventions Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 20. Answer: B False. Feedback: ICD-10-PCS has its guidelines for determining the sequencing when reporting more than one procedure provided during an encounter. This is always going to be determined in coordination with the diagnosis codes being reported to identify the medical necessity for performing these procedures. Learning Objective: 33.05 Topic: Selection of Principal Procedure Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute Let’s Check It! Rules and Regulations: 1. Answer: ICD-10-PCS codes may include any letter of the alphabet except the letters O and I. This is done to avoid any confusion between the letter O and the number 0, as well as any mix-up between the letter I and the number 1. Feedback: ICD-10-PCS codes may include any letter of the alphabet except the letters O and I. This is done to avoid any confusion between the letter O and the number 0, as well as any mix-up between the letter I and the number 1. Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: ICD-10-PCS codes have seven characters and are alphanumeric (both letters and numbers). Each of the seven positions in the code represents a specific piece of information relating to the procedure, service, or treatment provided.

Character Position Related Piece of Information 1. Section of the ICD-10-PCS code set 2. Body system upon which the procedure or service was performed 3. Root operation explains the category or type of procedure 4. Body part identifies the specific anatomical site involved in the procedure 5. Approach reports which method was used to perform the service or treatment 6. Device will report, when applicable, what type of device was involved in the service or procedure 7. Qualifier will add any additional detail Feedback: ICD-10-PCS codes have seven characters and are alphanumeric (both letters and numbers). Each of the seven positions in the code represents a specific piece of information relating to the procedure, service, or treatment provided. Character Position Related Piece of Information 1. Section of the ICD-10-PCS code set 2. Body system upon which the procedure or service was performed 3. Root operation explains the category or type of procedure 4. Body part identifies the specific anatomical site involved in the procedure 5. Approach reports which method was used to perform the service or treatment 6. Device will report, when applicable, what type of device was involved in the service or procedure 7. Qualifier will add any additional detail Learning Objective: 33.02 Topic: The Structure of ICD-10-PCS Codes Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: The ICD-10-PCS Tables are divided by body systems. Like all the other code sets, each section is in order by the first character in the code. Within each body system division of each section, the list continues in order by the root operation term for that procedure. Each section of the list has a grid that specifies the assigned meaning to each letter or number along with its position in the seven-character code. You will go through the grid and actually construct the correct code based on the physician‘s notes. As you have already learned, ICD-10-PCS codes are all seven characters. Therefore, you will build the code in this order, as directed by the grid. Feedback: The ICD-10-PCS Tables are divided by body systems. Like all the other code sets, each section is in order by the first character in the code. Within each

body system division of each section, the list continues in order by the root operation term for that procedure. Each section of the list has a grid that specifies the assigned meaning to each letter or number along with its position in the seven-character code. You will go through the grid and actually construct the correct code based on the physician‘s notes. As you have already learned, ICD-10-PCS codes are all seven characters. Therefore, you will build the code in this order, as directed by the grid. Learning Objective: 33.03 Topic: The ICD-10-PCS Book Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: A1. ICD-10-PCS codes are composed of seven characters. Each character is an axis of classification that specifies information about the procedure performed. Within a defined code range, a character specifies the same type of information in that axis of classification. A2. One of 34 possible values can be assigned to each axis of classification in the seven-character code: they are the numbers 0 through 9 and the alphabet (except I and O because they are easily confused with the numbers 1 and 0). The number of unique values used in an axis of classification differs as needed. A3. The valid values for an axis of classification can be added to as needed. A4. As with words in their context, the meaning of any single value is a combination of its axis of classification and any preceding values on which it may be dependent. A5. As the system is expanded to become increasingly detailed, over time more values will depend on preceding values for their meaning. A6. The purpose of the alphabetic index is to locate the appropriate table that contains all information necessary to construct a procedure code. The PCS Tables should always be consulted to find the most appropriate valid code. A7. It is not required to consult the index first before proceeding to the tables to complete the code. A valid code may be chosen directly from the tables.

A8. All seven characters must be specified to be a valid code. If the documentation is incomplete for coding purposes, the physician should be queried for the necessary information. A9. Within a PCS table, valid codes include all combinations of choices in characters 4 through 7 contained in the same row of the table. A10. ―And,‖ when used in a code description, means ―and/or.‖ A11. Many of the terms used to construct PCS codes are defined within the system. It is the coder‘s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear. Feedback: A1. ICD-10-PCS codes are composed of seven characters. Each character is an axis of classification that specifies information about the procedure performed. Within a defined code range, a character specifies the same type of information in that axis of classification. A2. One of 34 possible values can be assigned to each axis of classification in the seven-character code: they are the numbers 0 through 9 and the alphabet (except I and O because they are easily confused with the numbers 1 and 0). The number of unique values used in an axis of classification differs as needed. A3. The valid values for an axis of classification can be added to as needed. A4. As with words in their context, the meaning of any single value is a combination of its axis of classification and any preceding values on which it may be dependent. A5. As the system is expanded to become increasingly detailed, over time more values will depend on preceding values for their meaning. A6. The purpose of the alphabetic index is to locate the appropriate table that contains all information necessary to construct a procedure code. The PCS Tables should always be consulted to find the most appropriate valid code. A7. It is not required to consult the index first before proceeding to the tables to complete the code. A valid code may be chosen directly from the tables.

A8. All seven characters must be specified to be a valid code. If the documentation is incomplete for coding purposes, the physician should be queried for the necessary information. A9. Within a PCS table, valid codes include all combinations of choices in characters 4 through 7 contained in the same row of the table. A10. ―And,‖ when used in a code description, means ―and/or.‖ A11. Many of the terms used to construct PCS codes are defined within the system. It is the coder‘s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear. Learning Objective: 33.04 Topic: ICD-10-PCS General Conventions Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: The following instructions should be applied in the selection of principal procedure and clarification on the importance of the relation to the principal diagnosis when more than one procedure is performed: 1. Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis a. Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure. 2. Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis a. Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure 3. A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis.

a. Sequence diagnostic procedure as principal procedure, since the procedure most related to the principal diagnosis takes precedence. 4. No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis a. Sequence procedure performed for definitive treatment of secondary diagnosis as principal procedure, since there are no procedures (definitive or nondefinitive treatment) related to principal diagnosis. Feedback: The following instructions should be applied in the selection of principal procedure and clarification on the importance of the relation to the principal diagnosis when more than one procedure is performed: 5. Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis a. Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure. 6. Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis b. Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure 7. A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis. b. Sequence diagnostic procedure as principal procedure, since the procedure most related to the principal diagnosis takes precedence. 8. No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis b. Sequence procedure performed for definitive treatment of secondary diagnosis as principal procedure, since there are no procedures (definitive or nondefinitive treatment) related to principal diagnosis. Learning Objective: 33.05 Topic: Selection of Principal Procedure Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Application: The ICD-10-PCS codes are also provided for the convenience of the instructor. Application 1: WELLINGTON, ALISHA Answer: C Removal, Insertion and Fluoroscopy Feedback: What is/are the root operation term(s)? Replacement Fluoroscopy Removal, Insertion and Fluoroscopy Removal 0TPB8YZ Removal of device from>Bladder 0THB8YZ Insertion of device in>bladder BT1DZZZ Fluoroscopy of kidneys, ureters and bladder, right Learning Objective: 33.01 Learning Objective: 33.02 Learning Objective: 33.03 Learning Objective: 33.04 Learning Objective: 33.05 Topic: The Purpose of ICD-10-PCS Topic: The Structure of ICD-10-PCS Codes Topic: The ICD-10-PCS Book Topic: ICD-10-PCS General Conventions Topic: Selection of Principal Procedure Blooms: Analyze CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes Application 2: FIELDING, STEPHEN Answer: Repair Feedback: What is the root operation term? 1. Repair 2. Eyelid

3. External 4. Bite 08QPXZZ Repair, upper eyelid, left, external approach Learning Objective: 33.01 Learning Objective: 33.02 Learning Objective: 33.03 Learning Objective: 33.04 Learning Objective: 33.05 Topic: The Purpose of ICD-10-PCS Topic: The Structure of ICD-10-PCS Codes Topic: The ICD-10-PCS Book Topic: ICD-10-PCS General Conventions Topic: Selection of Principal Procedure Blooms: Analyze CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes Application 3: O’LEARY, KEVIN Answer: Excision and Replacement Feedback: What is/are the root operation term(s)? 1. Excision 2. Excision and Replacement 3. Replacement and Neck 4. Neck 0HBJXZZ Excision, skin, left upper leg 0HR4X74 Replacement, skin, neck, external approach, autologous tissue substitute Learning Objective: 33.01 Learning Objective: 33.02 Learning Objective: 33.03 Learning Objective: 33.04 Learning Objective: 33.05 Topic: The Purpose of ICD-10-PCS Topic: The Structure of ICD-10-PCS Codes Topic: The ICD-10-PCS Book Topic: ICD-10-PCS General Conventions Topic: Selection of Principal Procedure Blooms: Analyze CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes Application 4: SWANSONN, HANS Answer: Excision Feedback: What is the root operation term? 1. Diagnostic 2. Excision 3. Bladder 4. Endoscopic 0TBB8ZX Excision, diagnostic, of bladder, via natural opening endoscopic Learning Objective: 33.01 Learning Objective: 33.02 Learning Objective: 33.03 Learning Objective: 33.04 Learning Objective: 33.05 Topic: The Purpose of ICD-10-PCS Topic: The Structure of ICD-10-PCS Codes Topic: The ICD-10-PCS Book Topic: ICD-10-PCS General Conventions Topic: Selection of Principal Procedure Blooms: Analyze CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes Application 5: ZANDER, MARISSA Answer: Extraction and Transfusion Feedback: What is/are the root operation term(s)? 1. Extraction 2. Transfusion 3. Percutaneous 4. Extraction and Transfusion 10D00Z0 Extraction of Products of Conception, open, classical incision 30233H1 Transfusion, whole blood, percutaneous, peripheral vein, nonautologous Learning Objective: 33.01 Learning Objective: 33.02 Learning Objective: 33.03

Learning Objective: 33.04 Learning Objective: 33.05 Topic: The Purpose of ICD-10-PCS Topic: The Structure of ICD-10-PCS Codes Topic: The ICD-10-PCS Book Topic: ICD-10-PCS General Conventions Topic: Selection of Principal Procedure Blooms: Analyze CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes

Chapter 34 ICD-10-PCS Medical and Surgical Section 2024 Compliant Learning Outcomes LO 34.1 Identify the section and body systems used in Medical and Surgical Section codes. LO 34.2 Interpret the procedure to determine the accurate root operation term used in Medical and Surgical Section codes. LO 34.3 Utilize knowledge of anatomy to determine the body part treated to be used in Medical and Surgical Section codes. LO 34.4 Identify the approach used to accomplish the procedure used in Medical and Surgical Section codes. LO 34.5 Distinguish the type of device implanted, when applicable, for Medical and Surgical Section codes. LO 34.6 Select the appropriate qualifier character for Medical and Surgical Section codes. LO 34.7 Determine the correct way to report multiple and discontinued procedures for Medical and Surgical Section codes. LO 34.8 Analyze all of the details to build an accurate seven-character code for Medical and Surgical Section codes. Chapter Outline Learning Outcomes Key Terms

Medical/Surgical Section/Body Systems: Characters 1 and 2 Character Position 1: Medical and Surgical Section 0 (Zero) Character Position 2: Body System Medical/Surgical Root Operation: Character 3 Medical/Surgical Body Parts: Character 4 Medical/Surgical Approaches: Character 5 Medical/Surgical Devices: Character 6 Medical/Surgical Qualifiers: Character 7 Multiple and Discontinued Procedures in Medical and Surgical Cases Multiple Procedures Discontinued Procedures Medical/Surgical Coding: Putting It All Together Chapter Summary Chapter 34 Review Let‘s Check It! Terminology Let‘s Check It! Concepts Let‘s Check It! Guidelines Let‘s Check It! Rules and Regulations Let‘s Check It! Anatomical Term: ICD-10-PCS Value You Code It! Practice You Code It! Application Chapter Overview Medical and surgical procedures, services, and treatments are reported with codes from this first section of the tables of ICD-10-PCS. As the codes are subdivided by anatomical site or organ system that is the focus of the procedure, you will find that building a code to report this is quite different than using the other code sets. This coding process may require you to use your knowledge in a slightly different manner. Additional information about ICD-10-PCS can be found at: https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-PCS-andGEMs.html Discussion Activities 1. The root operative terms differ from some of the main terms used by CPT to describe the procedure, service, or treatment. Identify a root operative term and create a scenario using it. Include the ICD-10-PCS code used to report that procedure. (Learning Outcome: 34.2) Have students choose from the list of root operative terms for the Medical and Surgical section, or assign them to ensure that all terms are discussed. 2. Explain, in your own words the difference between the body system described by Character 2 and the body part described by Character 4 in the Medical and Surgical section of ICD-10-PCS. Include a specific example of each. (Learning Outcomes: 34.1). Have students compare and contrast various body parts listed from a specific subsection of the Medical and Surgical section.

Additional Resources 2022 ICD-10-PCS and GEMs (CMS): https://www.cms.gov/medicare/icd-10/2022-icd10-pcs

A Brief History of ICD-10-PCS (AHIMA): http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_0 04938.hcsp?dDocName=bok3_004938 AAPC: www.aapc.com American Health Information Management Association: www.ahima.org American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org Chapter 34 Review Answer Key Let’s Check It! Terminology Answer: 1. B Character 2. A Approach 3. C Root Operation Term Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.04 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Approaches: Character 5 Blooms: Remember CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: C The body part (specific anatomical side) Feedback: The fourth character position represents the body part Character Position 1 2 3 4

Character Meaning Section of the ICD-10-PCS book Body system being treated Root operation term Body part (specific anatomical site)

5 6 7

Approach used by physician Device, if applicable Qualifier, if applicable

Learning Objective: 34.01 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 2. Answer: B G Feedback: The character position 2 that identifies the endocrine system is G. Learning Objective: 34.01 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 3. Answer: D O and I Feedback: There is a 0 (zero) and a number 1 (one) but no letter O or letter I. The creators of this code set did this purposely, to avoid confusion. Learning Objective: 34.01 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 4. Answer: A root operation. Feedback:

According to the Official Guidelines for Coding and Reporting B2.1a, the example - Control of postoperative hemorrhage is coded to the root operation Control found in the general anatomical regions body systems. Learning Objective: 34.02 Topic: Medical/Surgical Root Operations: Character 3 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 5. Answer: B Upper Veins. Feedback: According to the Official Guidelines for Coding and Reporting B2.1b, the example - Vein body parts above the diaphragm are found in the Upper Veins body system. Learning Objective: 34.01 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: B 3 Feedback: Character Position 3 represents the root operation. Character Character Meaning Position 1 Section of the ICD-10-PCS book 2 Body system being treated 3 Root operation term 4 Body part (specific anatomical site) 5 Approach used by physician 6 Device, if applicable 7 Qualifier, if applicable Learning Objective: 34.02

Topic: Medical/Surgical Root Operations: Character 3 Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 7. Answer: C 0W4M0K0 Feedback: Creation of a vagina in male perineum with nonautologous tissue substitute, open approach would be coded with 0W4M0K0 Index: Creation>perineum>male 0W4M0----Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character W Character 3: Root Operation: Character 4 Character 4: Body Part: Character M Character 5: Approach: Character 0 Character 6: Device: Character K Character 7: Qualifier: Character 0 Learning Objective: 34.02 Topic: Medical/Surgical Root Operations: Character 3 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: A resection. Feedback: According to the Official Guidelines for Coding and Reporting B3.7, the example - Resection of spleen to stop post-procedural bleeding is coded to Resection instead of Control. Learning Objective: 34.02 Topic: Medical/Surgical Root Operations: Character 3 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute

9. Answer: D 08D8XZZ Feedback: Extraction of the right cornea, external approach would be coded 08D8XZZ Index: Extraction>cornea>right 08D8XZ--Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character 8 Character 3: Root Operation: Character D Character 4: Body Part: Character 8 Character 5: Approach: Character X Character 6: Device: Character Z Character 7: Qualifier: Character Z Learning Objective: 34.02 Topic: Medical/Surgical Root Operations: Character 3 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 10. Answer: B occlusion. Feedback: The complete closing of an orifice or lumen of a tubular body part is known as occlusion. Learning Objective: 34.02 Topic: Medical/Surgical Root Operations: Character 3 Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 11. Answer: C division. Feedback: According to the Official Guidelines for Coding and Reporting B3.14, the example - Freeing a nerve root from surrounding scar tissue to relieve pain is coded to the root operation Release. Severing a nerve root to relieve pain is coded to the root operation Division. Learning Objective: 34.02 Topic: Medical/Surgical Root Operations: Character 3

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 12. Answer: D inspection Feedback: Diagnostic arthroscopy would be interpreted as an inspection. Learning Objective: 34.02 Topic: Medical/Surgical Root Operations: Character 3 Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 13. Answer: B restriction Feedback: An esophagogastic fundoplication would be interpreted as a restriction. Learning Objective: 34.02 Topic: Medical/Surgical Root Operations: Character 3 Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 14. Answer: C Lower Intestinal Tract Feedback: The Lower Intestinal Tract includes: jejunum, ileum, cecum, large intestine, all the way to and including the anus. Learning Objective: 34.01 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 2 Medium Est Time: 0-1 minute 15. Answer: B Body Part Key Feedback: The appendix entitled Body Part Key in your ICD-10-PCS can help you when a specific anatomical site is documented and the body part components are not as specific. Learning Objective: 34.03 Topic: Medical/Surgical Body Parts: Character 4 Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 16. Answer: C Percutaneous Feedback: The percutaneous approach is the entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure and is identified with the character 3. Learning Objective: 34.04 Topic: Medical/Surgical Approaches: Character 5 Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 17. Answer: D 0TQD8ZZ Feedback: Endoscopic repair of the urethra via natural opening would be coded 0TQD8ZZ Index: Repair>urethra 0TQD---Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character T Character 3: Root Operation: Character Q Character 4: Body Part: Character D Character 5: Approach: Character 8 Character 6: Device: Character Z

Character 7: Qualifier: Character Z Learning Objective: 34.04 Topic: Medical/Surgical Approaches: Character 5 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 18. Answer: B J Feedback: An implanted cardiac lead, pacemaker device is represented by the sixth character J. Learning Objective: 34.05 Topic: Medical/Surgical Devices: Character 6 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 19. Answer: A X Feedback: The qualifier character option to explain that a procedure was for diagnostic purposes is identified by the character X. Learning Objective: 34.06 Topic: Medical/Surgical Qualifiers: Character 7 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 20. Answer: A 0C9W000 Feedback: Single upper tooth drainage device implant, open approach would be coded 0C9W000 Index: Drainage>tooth>upper 0C9W-----

Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character C Character 3: Root Operation: Character 9 Character 4: Body Part: Character W Character 5: Approach: Character 0 Character 6: Device: Character 0 Character 7: Qualifier: Character 0 Learning Objective: 34.05 Topic: Medical/Surgical Devices: Character 6 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Let’s Check It! Guidelines: 1. Answer: root operations Feedback: B3.4a Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic. Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes

2. Answer: overlapping, deepest Feedback: B3.5 If the root operations Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded. Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: bypassed Feedback: B3.6c If multiple coronary arteries are bypassed, a separate procedure is coded for each coronary artery that uses a different device and/or qualifier. Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4

Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: autograft Feedback: B3.9 If an autograft is obtained from a different procedure site in order to complete the objective of the procedure, a separate procedure is coded. Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: fused Feedback: B3.10b If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier.

Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6. Answer: Inspection Feedback: B3.11a Inspection of a body part(s) performed in order to achieve the objective of a procedure is not coded separately. Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: Release, freed Feedback: B3.13 In the root operation Release, the body part value coded is the body part being freed and not the tissue being manipulated or cut to free the body part. Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: Reposition, not Feedback: B3.15 Reduction of a displaced fracture is coded to the root operation Reposition and the application of a cast or splint in conjunction with the Reposition procedure is not coded separately. Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05

Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: separate Feedback: B4.7 If a body system does not contain a separate body part value for fingers, procedures performed on the fingers are coded to the body part value for the hand. Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 1-3 minutes 10. Answer: Open Feedback: B5.2 Procedures performed using the open approach with percutaneous endoscopic assistance are coded to the approach Open. Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: indirectly, External Feedback: B5.3b Procedures performed indirectly by the application of external force through the intervening body layers are coded to the approach External. Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4

Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 12. Answer: device, Percutaneous Feedback: B5.4 Procedures performed percutaneously via a device placed for the procedure are coded to the approach Percutaneous. Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 13. Answer: after Feedback: B6.1a A device is coded only if a device remains after the procedure is completed.

Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 14. Answer: only, coded Feedback: B6.1c Procedures performed on a device only and not on a body part are specified in the root operations Change, Irrigation, Removal and Revision, and are coded to the procedure performed. Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 15. Answer: drainage Feedback: B6.2 A separate procedure to put in a drainage device is coded to the root operation Drainage with the device value Drainage Device. Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: Character Position 1 2 3 4

Character Meaning Section of the ICD-10-PCS book Body system being treated Root operation term Body part (specific anatomical site)

5 6 7

Approach used by physician Device, if applicable Qualifier, if applicable

Character Position 1 2 3 4 5 6 7

Character Meaning Section of the ICD-10-PCS book Body system being treated Root operation term Body part (specific anatomical site) Approach used by physician Device, if applicable Qualifier, if applicable

Feedback:

Learning Objective: 34.01 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: If the documentation identifies a procedure was performed on both a right body part and a left body part, and a body part code character is available to report the bilateral procedure, that is the one code to report. However, if there is no code character available to report a bilateral procedure, then you will need to report two codes: one for each procedure. Feedback: If the documentation identifies a procedure was performed on both a right body part and a left body part, and a body part code character is available to report the bilateral procedure, that is the one code to report. However, if there is no code character available to report a bilateral procedure, then you will need to report two codes: one for each procedure. Learning Objective: 34.03 Topic: Medical/Surgical Body Parts: Character 4

Blooms: Evaluate CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: The Body Part Key appendix in your ICD-10-PCS can help you when a specific anatomical site is documented and the body part components are not as specific. Feedback: The Body Part Key appendix in your ICD-10-PCS can help you when a specific anatomical site is documented and the body part components are not as specific. Learning Objective: 34.03 Topic: Medical/Surgical Body Parts: Character 4 Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: The seven approaches used within the Medical and Surgical section are, in any order: 1. Open: Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure … Character 0 2. Percutaneous: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure. … Character 3 3. Percutaneous Endoscopic: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure … Character 4 4. Via Natural or Artificial Opening: Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure … Character 7 5. Via Natural or Artificial Opening Endoscopic: Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure … Character 8

6. Via Natural or Artificial Opening with Precutaneous Endoscopic assistance: Entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure….Character F 7. External: Procedure performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane … Character X Feedback: The seven approaches used within the Medical and Surgical section are, in any order: 1. Open: Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure … Character 0 2. Percutaneous: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure. … Character 3 3. Percutaneous Endoscopic: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure … Character 4 4. Via Natural or Artificial Opening: Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure … Character 7 5. Via Natural or Artificial Opening Endoscopic: Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure … Character 8 6. Via Natural or Artificial Opening with Precutaneous Endoscopic assistance: Entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure….Character F 7. External: Procedure performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane … Character X Learning Objective: 34.04 Topic: Medical/Surgical Approaches: Character 5 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5.

Answer: The office guidelines provide 4 cases when you will report multiple codes as follows: 1. The same root operation is performed on different body parts as defined by distinct values of the body part character. Two codes are reported 2. The same root operation is repeated at different body sites that are included in the same body part value. You will report the same code twice. It is recommended that a report to explain is appended. 3. Multiple root operations with distinct objectives are performed on the same body part. Two codes are reported, one for each root operation. 4. The intended root operation is attempted using one approach, but is converted to a different approach. One code will report what was actually accomplished with the first approach, and a second code will report the second approach. Feedback: The office guidelines provide 4 cases when you will report multiple codes as follows: 1. The same root operation is performed on different body parts as defined by distinct values of the body part character. Two codes are reported 2. The same root operation is repeated at different body sites that are included in the same body part value. You will report the same code twice. It is recommended that a report to explain is appended. 3. Multiple root operations with distinct objectives are performed on the same body part. Two codes are reported, one for each root operation. 4. The intended root operation is attempted using one approach, but is converted to a different approach. One code will report what was actually accomplished with the first approach, and a second code will report the second approach. The intended root operation is attempted using one approach, but is converted to a different approach. One code will report what was actually accomplished with the first approach, and a second code will report the second approach. Learning Objective: 34.07 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Let’s Check It! Anatomical Term – ICD-10-PCS Value 1. Answer: Pons Feedback: Apneustic center: Pons

Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer:

Nasal Mucosa and Soft Tissue

Feedback: Columella: Nasal Mucosa and Soft Tissue Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: Intracranial vein Feedback: Dural venous sinus: Intracranial vein Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: Trigeminal Nerve Feedback: Fifth cranial nerve: Trigeminal Nerve Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07

Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: Hepatic Artery Feedback: Gastroduodenal artery: Hepatic Artery Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 6.

Answer: Lumbar Plexus Feedback: Genitofemoral nerve: Lumbar Plexus Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 7. Answer: Thoracic Sympathetic Nerve Feedback: Inferior cardiac nerve: Thoracic Sympathetic Nerve Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7

Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 8. Answer: Hypothalamus Feedback: Mammillary body: Hypothalamus Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 9. Answer: Buccal Mucosa Feedback: Palatine gland: Buccal Mucosa Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03

Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 10. Answer: Vagus Nerve Feedback: Recurrent laryngeal nerve: Vagus Nerve Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 1-3 minutes 11. Answer: Tongue, Palate, Pharynx Muscle Feedback: Stylopharyngeus muscle: Tongue, Palate, Pharynx Muscle Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 12. Answer: Glossopharyngeal Nerve Feedback: Tympanic nerve: Glossopharyngeal Nerve Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3

Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 13. Answer: Larynx Feedback: Ventricular fold: Larynx Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 14. Answer: Sternum Feedback:

Xiphoid process: Sternum Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 15. Answer: Facial Muscle Feedback: Zygomaticus muscle: Facial Muscle Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes You Code It! Practice 1. Answer: 0CTQ0ZZ Feedback: Correct code: 0CTQ0ZZ Index: Adenoidectomy>resection>adenoids 0CTQ--Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character C Character 3: Root Operation: Character T Character 4: Body Part: Character Q Character 5: Approach: Character 0 Character 6: Device: Character Z Character 7: Qualifier: Character Z Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2.

Answer: 0FT44ZZ Feedback: Correct code: 0FT44ZZ Index: Cholecystectomy>resection>gallbladder 0FT4--Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character F Character 3: Root Operation: Character T Character 4: Body Part: Character 4 Character 5: Approach: Character 4 Character 6: Device: Character Z Character 7: Qualifier: Character Z Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: 04BA4ZX Feedback: Correct code: 04BA4ZX Index: Biopsy>excision>artery>renal>left 04BA--Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character 4 Character 3: Root Operation: Character B Character 4: Body Part: Character A Character 5: Approach: Character 4

Character 6: Device: Character Z Character 7: Qualifier: Character X Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: 0QBN0ZZ Feedback: Correct code: 0QBN0ZZ Index: Bunionectomy>excision>metatarsal>right 0QBN--Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character Q Character 3: Root Operation: Character B Character 4: Body Part: Character N Character 5: Approach: Character 0 Character 6: Device: Character Z Character 7: Qualifier: Character Z Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08

Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: 0BJ08ZZ Feedback: Correct code: 0BJ08ZZ Index: Bronchoscopy 0BJ08ZZ Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character B Character 3: Root Operation: Character J Character 4: Body Part: Character 0 Character 5: Approach: Character 8 Character 6: Device: Character Z Character 7: Qualifier: Character Z Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 6. Answer: 0SRC0KZ Feedback: Correct code: 0SRC0KZ Index: Arthroplasty>replacement>joint>knee 0SR---Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character S Character 3: Root Operation: Character R Character 4: Body Part: Character C Character 5: Approach: Character 0 Character 6: Device: Character K Character 7: Qualifier: Character Z Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 7. Answer: 09023ZZ Feedback:

Correct code: 09023ZZ Index: Alteration>ear>bilateral 0902--Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character 9 Character 3: Root Operation: Character 0 Character 4: Body Part: Character 2 Character 5: Approach: Character 3 Character 6: Device: Character Z Character 7: Qualifier: Character Z Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 8. Answer: 0D124Z6 Feedback: Correct code: 0D124Z6 Index: Bypass>esophagus>middle 0D12--Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character D Character 3: Root Operation: Character 1 Character 4: Body Part: Character 2 Character 5: Approach: Character 4 Character 6: Device: Character Z Character 7: Qualifier: Character 6 Learning Objective: 34.01

Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 9. Answer: 0T2BX0Z Feedback: Correct code: 0T2BX0Z Index: Change device in>bladder 0T2BX-Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character T Character 3: Root Operation: Character 2 Character 4: Body Part: Character B Character 5: Approach: Character X Character 6: Device: Character 0 Character 7: Qualifier: Character Z Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4

Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 10. Answer: 0Y6Y0Z0 Feedback: Correct code: 0Y6Y0Z0 Index: Amputation>detachment>toe>5th>left 0Y6Y0ZCharacter 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character Y Character 3: Root Operation: Character 6 Character 4: Body Part: Character Y Character 5: Approach: Character 0 Character 6: Device: Character Z Character 7: Qualifier: Character 0 Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 3-5 minutes 11. Answer: 0FJD8ZZ Feedback: Correct code: 0FJD8ZZ Index: Inspection>duct>pancreatic 0FJD--Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character F Character 3: Root Operation: Character J Character 4: Body Part: Character D Character 5: Approach: Character 8 Character 6: Device: Character Z Character 7: Qualifier: Character Z Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 12. Answer: 0UL74ZZ Feedback: Correct code: 0UL74ZZ Index: Ligation>occlusion>fallopian tubes, bilateral 0UL7--Character 1: Section: Medical and Surgical: Character 0

Character 2: Body System: Character U Character 3: Root Operation: Character L Character 4: Body Part: Character 7 Character 5: Approach: Character 4 Character 6: Device: Character Z Character 7: Qualifier: Character Z Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 13. Answer: 0W3F0ZZ Feedback: Correct code: 0W3F0ZZ Index: Control postoperative bleeding in>abdominal wall 0W3F--Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character W Character 3: Root Operation: Character 3 Character 4: Body Part: Character F Character 5: Approach: Character 0 Character 6: Device: Character Z Character 7: Qualifier: Character Z Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04

Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 14. Answer: 0DH64UZ Feedback: Correct code: 0DH64UZ Index: Feeding device>insertion of device in>stomach 0DH6--Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character D Character 3: Root Operation: Character H Character 4: Body Part: Character 6 Character 5: Approach: Character 4 Character 6: Device: Character U Character 7: Qualifier: Character Z Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7

Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 15. Answer: 00K83ZZ Feedback: Correct code: 00K83ZZ Index: Map>basal ganglia 00K8--Character 1: Section: Medical and Surgical: Character 0 Character 2: Body System: Character 0 Character 3: Root Operation: Character K Character 4: Body Part: Character 8 Character 5: Approach: Character 3 Character 6: Device: Character Z Character 7: Qualifier: Character Z Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

You Code It! Application Application 1: FASCHEL, MARTIN Answer: 0WH63YZ Feedback: 0WH63YZ: Alphabetic Index>insertion of a device in>Neck Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: TUTTLE, BARBIE Answer: 0SRB04A Feedback: 0SRB04A: Alphabetic Index>Arthroplasty see Replacement, Lower Joint Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2

Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: LATCHMAN, VICTOR Answer: 0RSL0ZZ Feedback: 0RSL0ZZ: Alphabetic Index>Reposition>Joint>Elbow>right

Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: MAGGUIOTT, FELIX

Answer: 0YU60JZ Feedback: 0YU60JZ: Alphabetic Index>Herniorraphy>with synthetic substitute>see Supplement Anatomical Region, Lower Extremities Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2 Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: KENSINGTON, LOUIS Answer: 0DQQ0ZZ, 0D8R0ZZ, 0DJD8ZZ Feedback: 0DQQ0ZZ: Alphabetic Index>Anoplasty>see Repair, Anus 0D8R0ZZ: Alphabetic Index>Sphincterotomy, anal>see Division, Anal Sphincter 0DJD8ZZ: Alphabetic Index>inspection>intestinal tract>lower Learning Objective: 34.01 Learning Objective: 34.02 Learning Objective: 34.03 Learning Objective: 34.04 Learning Objective: 34.05 Learning Objective: 34.06 Learning Objective: 34.07 Learning Objective: 34.08 Topic: Medical/Surgical Section/Body Systems: Characters 1 and 2

Topic: Medical/Surgical Root Operations: Character 3 Topic: Medical/Surgical Body Parts: Character 4 Topic: Medical/Surgical Approaches: Character 5 Topic: Medical/Surgical Devices: Character 6 Topic: Medical/Surgical Qualifiers: Character 7 Topic: Multiple and Discontinues Procedures in Medical and Surgical Cases Topic: Medical/Surgical Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 35 Obstetrics Section 2024 Compliant Learning Outcomes

LO 35.1 Recognize the details reported in the Obstetrics Section of ICD-10-PCS. LO 35.2 Interpret the procedure to determine the accurate Obstetrics root operation term. LO 35.3 Employ your knowledge of anatomy to determine the body part treated in Obstetrics coding. LO 35.4 Determine the approach used for the Obstetrics procedure. LO 35.5 Identify any devices that will stay with the body after an Obstetrics procedure. LO 35.6 Utilize the details required to report the correct qualifier for an Obstetrics code. LO 35.7 Analyze all of the details to build an accurate seven-character Obstetrics code. Chapter Outline Learning Outcomes Key Terms Introduction Obstetrics Section/Body System: Characters 1 and 2 Obstetrics Root Operations: Character 3 Obstetrics Body Parts: Character 4 Obstetrics Approaches: Character 5 Obstetrics Devices: Character 6 Obstetrics Qualifiers: Character 7 Obstetrics Coding: Putting It All Together Chapter Summary Chapter 35 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Root Operation Definitions – Obstetrics Let’s Check It! Guidelines Let’s Check It! Rules and Regulations

You Code It! Practice You Code It! Application Chapter Overview After the Medical and Surgical section are additional sections with a narrower scope of details for procedures that differ from those already represented in that first section of this code set. Most of these are obvious as to their contents by their title: Obstetrics. Obstetrics is the medical specialty that focuses on the care of pregnant women. The relationship between the physician—the obstetrician—and the patient often begins prior to conception and lasts all the way through gestation through delivery to the postpartum period. The entire scope of this care is not an issue for coders in a hospital. However, there will be times when a pregnant woman might be admitted into a hospital requiring acute care for the embryo or fetus. These are the procedures and services reported from this section. Additional information about ICD-10-PCS can be found at: https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-PCS-and-GEMs.html Discussion Activities 1. Identify a root operative term from the Obstetrics section and create a scenario using it. Include the ICD-10-PCS code used to report that procedure. (Learning Outcome: 35.2) 2. Explain, in your own words the different approaches a physician can use to reach the products of conception. Include a specific example for at least two. (Learning Outcome: 35.4) Additional Resources 2022 ICD-10-PCS and GEMS https://www.cms.gov/medicare/icd-10/2022-icd-10-pcs A Brief History of ICD-10-PCS (AHIMA): http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_004938.hcsp?dDocName=bok3_004 938 AAPC: www.aapc.com American Health Information Management Association: www.ahima.org American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org Chapter 35 Review Answer Key

Let’s Check It! Terminology Answer: 1. A Abortifacient 2. C Products of Conception 3. B Laminaria Learning Objective: 35.03 Learning Objective: 35.06 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Qualifiers: Character 7 Blooms: Remember CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: C Approach. Feedback: Character Position Character Meaning 1 Section of the ICD-10-PCS book 2 Body system being treated 3 Root operation term 4 Body part (specific anatomical site) 5 Approach used by physician 6 Device, if applicable 7 Qualifier, if applicable Learning Objective: 35.04 Topic: Obstetrics Approaches: Character 5 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 2. Answer: D 1 Feedback: All of the codes reporting an obstetrics procedure will begin with the section number one (1). Learning Objective: 35.01 Topic: Obstetrics Section/Body System: Characters 1 and 2 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 3. Answer: D all of these. Feedback: The products of conception include the zygote, embryo, or fetus, as well as the amnion, umbilical cord, and placenta.

Learning Objective: 35.03 Topic: Obstetrics Body Parts: Character 4 Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 4. Answer: C delivery. Feedback: All of the following are root operative terms in the Obstetric Section: 1. Abortion: Artificially terminating a pregnancy … Character: A 2. Change: Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane … Character: 2 3. Delivery: Assisting the passage of the products of conception from the genital canal … Character E 4. Drainage: Taking or letting out fluids and/or gases from a body part … Character 9 5. Extraction: Pulling or stripping out or off all or a portion of a body part by the use of force … Character D 6. Insertion: Putting in nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part … Character H 7. Inspection: Visually and/or manually exploring a body part … Character J 8. Removal: Taking out or off a device from a body part … Character P 9. Repair: Restoring, to the extent possible, a body part to its normal anatomic structure and function … Character Q 10. Reposition: Moving to its normal location or other suitable location all or a portion of a body part…Character S 11. Resection: Cutting out or off, without replacement, all of a body part … Character T 12. Transplantation: Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part … Character Y _______________ Irrigation is found under the Administration Section: Putting in or on a cleansing substance … Character 1 Learning Objective: 35.02 Topic: Obstetrics Root Operations: Character 3 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 5. Answer: B Percutaneous endoscopic. Feedback: Within the Obstetric Section - Character Position 5: Approach - The approach to an intrauterine cordocentesis would be a percutaneous endoscopic approach. Learning Objective: 35.02 Topic: Obstetrics Root Operations: Character 3 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: A 10J17ZZ Feedback: 10J17ZZ Alphabetic index>Inspection>products of conception>retained Learning Objective: 35.04 Topic: Obstetrics Approaches: Character 5 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: C device. Feedback: Character Position Character Meaning 1 Section of the ICD-10-PCS book 2 Body system being treated (Pregnancy) 3 Root operation term 4 Body part (Products of Conception) 5 Approach used by physician 6 Device 7 Qualifier

Learning Objective: 35.05 Topic: Obstetrics Devices: Character 6 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: B 4 Feedback: During a delivery, if the physician uses forceps or another assisting mechanism, this delivery becomes an extraction, and the additional detail will be reported with the Qualifier character: 1. Low forceps … Character 3 2. Mid forceps … Character 4 3. High forceps … Character 5 4. Vacuum … Character 6 5. Internal version … Character 7 6. Other … Character 8 Learning Objective: 35.06 Topic: Obstetrics Qualifiers: Character 7 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: D H Feedback: In Utero Procedures The Qualifier character will report the body system that was repaired or transplanted during an in utero procedure performed on the fetus (root operation repair or transplantation). Nervous system … E Hepatobiliary and pancreas … N Cardiovascular system … F Endocrine system … P Lymphatics and hemic … G Skin … Q Eye … H Musculoskeletal system … R Ear, nose, and sinus … J Urinary system … S Respiratory system … K Female reproductive system … T

Mouth and throat … L Male reproductive system … V Gastrointestinal system … M Other body system … Y Learning Objective: 35.06 Topic: Obstetrics Qualifiers: Character 7 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 10. Answer: B 0 Feedback: Within the Obstetric section, what is the one body system that is the gestational term: In this section there is only one body system that is the gestational term: 0 Pregnancy Learning Objective: 35.01 Topic: Obstetrics Section/Body System: Characters 1 and 2 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Let’s Check It! Character 3 Definitions Answer: 1. C E 2. F P 3. I T 4. A A 5. E J 6. D H 7. G Q 8. H S 9. J Y 10. B D Feedback: 1. C E 2. F P 3. I T

4. A A 5. E J 6. D H 7. G Q 8. H S 9. J Y 10. B D Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Let’s Check It! Guidelines Obstetric Section Guidelines (section 1) 1. Answer: Obstetrics Feedback: Procedures performed on the products of conception are coded to the Obstetrics section. Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3

Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 2. Answer: pregnant, Medical Surgical Feedback: Procedures performed on the pregnant female other than the products of conception are coded to the appropriate root operation in the Medical and Surgical section. Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 3. Answer: Amniocentesis, obstetric Feedback: Amniocentesis is coded to the products of conception body part in the Obstetrics section. Repair of obstetric urethral laceration is coded to the urethra body part in the Medical and Surgical section.

Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 4. Answer: delivery, retained, all, Extraction Feedback: Procedures performed following a delivery or abortion for curettage of the endometrium or evacuation of retained products of conception are all coded in the Obstetrics section, to the root operation Extraction and the body part Products of Conception, Retained. Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes 5. Answer: therapeutic, postpartum, Endometrium Feedback: Diagnostic or therapeutic dilation and curettage performed during times other than the postpartum or post-abortion period are all coded in the Medical and Surgical section, to the root operation Extraction and the body part Endometrium. Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 1-3 minutes Let’s Check It! Rules and Regulations: 1. Answer: A delivery is to assisting the passage of the products of conception from the genital canal and is presented with the character E An extraction is the pulling or stripping out or off all or a portion of a body part by the use of force and is represented with the character D Feedback: A delivery is to assisting the passage of the products of conception from the genital canal and is presented with the character E An extraction is the pulling or stripping out or off all or a portion of a body part by the use of force and is represented with the character D Learning Objective: 35.02

Topic: Obstetrics Root Operations: Character 3 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: The Obstetrics – Character Position 4 section focuses on three body parts, which are not specific anatomical sites. The three body parts are: 1. Products of conception, identified with the character 0 (zero) 2. Products of conception, retained, identified with the character 1 3. Products of conception, ectopic, identified with the character 2 Feedback: The Obstetrics – Character Position 4 section focuses on three body parts, which are not specific anatomical sites. The three body parts are: 1. Products of conception, identified with the character 0 (zero) 2. Products of conception, retained, identified with the character 1 3. Products of conception, ectopic, identified with the character 2 Learning Objective: 35.03 Topic: Obstetrics Body Parts: Character 4 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: The 6 approaches, their definitions and characters used in the Obstetric section of ICD-10-PCS are as follows: 1. Open: Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure … Character 0 2. Percutaneous: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure. … Character 3 3. Percutaneous Endoscopic: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure … Character 4

4. Via Natural or Artificial Opening: Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure … Character 7 5. Via Natural or Artificial Opening Endoscopic: Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure … Character 8 6. External: Procedure performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane … Character X Feedback: The 6 approaches, their definitions and characters used in the Obstetric section of ICD-10-PCS are as follows: 1. Open: Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure … Character 0 2. Percutaneous: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure. … Character 3 3. Percutaneous Endoscopic: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure … Character 4 4. Via Natural or Artificial Opening: Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure … Character 7 5. Via Natural or Artificial Opening Endoscopic: Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure … Character 8 6. External: Procedure performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane … Character X Learning Objective: 35.04 Topic: Obstetrics Approaches: Character 5 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: This seventh character position represents the Qualifier and is required. In some cases, there may be no more details to add, so you will use the placeholder letter Z No Qualifier – the equivalent to ―not applicable‖. Feedback:

This seventh character position represents the Qualifier and is required. In some cases, there may be no more details to add, so you will use the placeholder letter Z No Qualifier – the equivalent to ―not applicable‖. Learning Objective: 35.06 Topic: Obstetrics Qualifiers: Character 7 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: A cesarean Section is the extraction of the baby via surgical incision. This explanation leads you to the root operation term used in ICD-10-PCS, ―extraction‖. Feedback: A cesarean Section is the extraction of the baby via surgical incision. This explanation leads you to the root operation term used in ICD-10-PCS, ―extraction‖. Learning Objective: 35.06 Topic: Obstetrics Qualifiers: Character 7 Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Practice 1. Answer: 10A07Z6 Feedback: Correct code: 10A07Z6 Index: Abortion>products of conception>vacuum Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character A Character 4: Body Part: Character 0 Character 5: Approach: Character 7 Character 6: Device: Character Z Character 7: Qualifier: Character 6

Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: 10Q08ZS Feedback: Correct code: 10Q08ZS Index: Repair>products of conception Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character Q Character 4: Body Part: Character 0 Character 5: Approach: Character 8 Character 6: Device: Character Z Character 7: Qualifier: Character S Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6

Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: 10D07Z3, 0W8NXZZ Feedback: Correct code: 10D07Z3 Correct code: 0W8NXZZ 10D07Z3-Index: Exaction>products of conception>low forceps 0W8NXZZ- Index: Division>perineum>female First listed: Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character D Character 4: Body Part: Character 0 Character 5: Approach: Character 7 Character 6: Device: Character Z Character 7: Qualifier: Character 3 Second listed: Character 1: Section: Obstetrics: Character 0 Character 2: Body System: Character W Character 3: Root Operation: Character 8 Character 4: Body Part: Character N Character 5: Approach: Character X Character 6: Device: Character Z Character 7: Qualifier: Character Z Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7

Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: 102073Z Feedback: Correct code: 102073Z Index: Change device in>products of conception Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character 2 Character 4: Body Part: Character 0 Character 5: Approach: Character 7 Character 6: Device: Character 3 Character 7: Qualifier: Character Z Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: 10H07YZ

Feedback: Correct code: 10H07YZ Index: Insertion>products of conception Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character H Character 4: Body Part: Character 0 Character 5: Approach: Character 7 Character 6: Device: Character Y Character 7: Qualifier: Character Z Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: 10E0XZZ, 10907ZC Feedback: Correct code: 10E0XZZ Correct code: 10907ZC 10E0XZZ: Index: delivery>manually assisted 10907ZC: Index: AROM First listed Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character E Character 4: Body Part: Character 0 Character 5: Approach: Character X Character 6: Device: Character Z

Character 7: Qualifier: Character Z Second listed Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character 9 Character 4: Body Part: Character 0 Character 5: Approach: Character 7 Character 6: Device: Character Z Character 7: Qualifier: Character C Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: 10D07Z6 Feedback: Correct code: 10D07Z6 Index: Delivery>vacuum assisted – see Extraction, Products of conception Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character D Character 4: Body Part: Character 0 Character 5: Approach: Character 7 Character 6: Device: Character Z Character 7: Qualifier: Character 6 Learning Objective: 35.01 Learning Objective: 35.02

Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: 10A07ZW Feedback: Correct code: 10A07ZW Index: termination of pregnancy>luminaria Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character A Character 4: Body Part: Character 0 Character 5: Approach: Character 7 Character 6: Device: Character Z Character 7: Qualifier: Character W Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: 10Q00ZL Feedback: Correct code: 10Q00ZL Index: Repair>products of conception Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character Q Character 4: Body Part: Character 0 Character 5: Approach: Character 0 Character 6: Device: Character Z Character 7: Qualifier: Character L Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: 10900ZC Feedback:

Correct code: 10900ZC Index>drainage>products of conception>amniotic fluid>therapeutic Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character 9 Character 4: Body Part: Character 0 Character 5: Approach: Character 0 Character 6: Device: Character Z Character 7: Qualifier: Character C Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: 10J07ZZ Feedback: Correct Code: 10J07ZZ Index: Inspection>products of conception Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character J Character 4: Body Part: Character 0 Character 5: Approach: Character 7 Character 6: Device: Character Z Character 7: Qualifier: Character Z Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03

Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: 10D07Z5 Feedback: Correct code: 10D07Z5 Index>extraction>products of conception>high forceps Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character D Character 4: Body Part: Character 0 Character 5: Approach: Character 7 Character 6: Device: Character Z Character 7: Qualifier: Character 5 Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 13. Answer: 10A00ZZ Feedback: Correct code: 10A00ZZ Index: termination of pregnancy>hysterotomy Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character A Character 4: Body Part: Character 0 Character 5: Approach: Character 0 Character 6: Device: Character Z Character 7: Qualifier: Character Z Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: 10903ZA Feedback: Correct code: 10903ZA

Index>Drainage>products of conception>fetal cerebrospinal fluid Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character 9 Character 4: Body Part: Character 0 Character 5: Approach: Character 3 Character 6: Device: Character Z Character 7: Qualifier: Character A Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: 10Y07ZQ Feedback: Correct code: 10Y07ZQ Index: transplantation>products of conception Character 1: Section: Obstetrics: Character 1 Character 2: Body System: Character 0 Character 3: Root Operation: Character Y Character 4: Body Part: Character 0 Character 5: Approach: Character 7 Character 6: Device: Character Z Character 7: Qualifier: Character Q Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04

Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application Application 1: ALBERTS, SERITA Answer: 10D00Z1 Feedback: 10D00Z1: ICD-10-PCS index>extraction>products of conception>low cervical Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

Application 2: HUDSON, LYNN Answer: 10E0XZZ, 0W8NXZZ Feedback: 10E0XZZ: ICD-10-PCS index>delivery>manually assisted>external>no device>no qualifier 0W8NXZZ: Division … perineum, Female

Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: CARROLL, DAWN Answer: 10D00Z0 Feedback: 10D00Z0: ICD-10-PCS index>delivery>cesarean>open>no device>classical Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4

Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: FAULDS, MAGGIE Answer: 10D17ZZ Feedback: 10D17ZZ: ICD-10-PCS index>extraction>products of conception>retained Learning Objective: 35.01 Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: HOFFMEIER, KATHLEEN Answer: 10T24ZZ Feedback: 10T24ZZ: ICD-10-PCS index>resection>products of conception, ectopic Learning Objective: 35.01

Learning Objective: 35.02 Learning Objective: 35.03 Learning Objective: 35.04 Learning Objective: 35.05 Learning Objective: 35.06 Learning Objective: 35.07 Topic: Obstetrics Section/Body System: Characters 1 and 2 Topic: Obstetrics Root Operations: Character 3 Topic: Obstetrics Body Parts: Character 4 Topic: Obstetrics Approaches: Character 5 Topic: Obstetrics Devices: Character 6 Topic: Obstetrics Qualifiers: Character 7 Topic: Obstetrics Coding: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 36 Placement through Chiropractic Sections 2024 Compliant Learning Outcomes LO 36.1 Recognize the details reported in the Placement—Anatomical Regions Section and Placement—Anatomical Orifices Section. LO 36.2 Evaluate the details to determine the services reported from the Administration Section. LO 36.3 Determine the specifics required to build a code from the Measurement and Monitoring Section. LO 36.4 Interpret the documentation to report a service from the Extracorporeal or Systemic Assistance and Performance Section. LO 36.5 Abstract the documentation to determine a code for a service reported from the Extracorporeal or Systemic Therapies Section. LO 36.6 Utilize knowledge to report a code from the Osteopathic Section. LO 36.7 Identify the details necessary to build a code from the Other Procedures Section. LO 36.8 Distinguish the services provided to determine reporting a code from the Chiropractic Section.

LO 36.9 Analyze the documentation to build a complete and accurate code(s) in ICD-10-PCS for sections 2–9. Chapter Outline Learning Outcomes Key Terms Reporting Services from the Placement Section Character Definitions Character Position 1: Placement Section 2 Character Position 2: Anatomical Region/Orifices Character Position 3: Root Operation Character Position 4: Body Region Character Position 5: Approach Character Position 6: Device Character Position 7: Qualifier Reporting Services from the Administration Section Character Definitions Character Position 1: Administration Section 3 Character Position 2: Physiology System/Anatomical Region Character Position 3: Root Operation Character Position 4: Body System/Region Character Position 5: Approach Character Position 6: Substance Character Position 7: Qualifier Reporting Services from the Measurement and Monitoring Section Character Definitions Character Position 1: Measurement and Monitoring Section 4 Character Position 2: Physiology System Character Position 3: Root Operation Character Position 4: Body System Character Position 5: Approach Character Position 6: Function/Device Character Position 7: Qualifier Reporting from the Extracorporeal or Systemic Assistance and Performance Section Character Definitions Character Position 1: Extracorporeal or Systemic Assistance and Performance Section 5 Character Position 2: Physiology System Character Position 3: Root Operation Character Position 4: Body System Character Position 5: Duration Character Position 6: Function Character Position 7: Qualifier Reporting from the Extracorporeal or Systemic Therapies Section Character Definitions

Character Position 1: Extracorporeal or Systemic Therapies Section 6 Character Position 2: Physiology Systems Character Position 3: Root Operation Character Position 4: Body System Character Position 5: Duration Character Position 6: Qualifier Character Position 7: Qualifier Reporting Osteopathic Services Character Definitions Character Position 1: Osteopathic Section 7 Character Position 2: Anatomical Regions Character Position 3: Root Operation Character Position 4: Body Region Character Position 5: Approach Character Position 6: Method Character Position 7: Qualifier Reporting from the Other Procedures Section Character Definitions Character Position 1: Other Procedures Section 8 Character Position 2: Body System Character Position 3: Root Operation Character Position 4: Body Region Character Position 5: Approach Character Position 6: Method Character Position 7: Qualifier Reporting Inpatient Chiropractic Services Character Definitions Character Position 1: Chiropractic Section 9 Character Position 2: Anatomical Regions Character Position 3: Root Operation Character Position 4: Body Region Character Position 5: Approach Character Position 6: Method Character Position 7: Qualifier Sections 2-9: Putting It All Together Chapter Summary Chapter 36 Review Let‘s Check It! Terminology Let‘s Check It! Concepts Let‘s Check It! Rules and Regulations You Code It! Practice You Code It! Application Chapter Overview After the Medical and Surgical and Obstetrics sections are additional sections with a narrower scope of details for procedures that differ from those already represented in that first section of this code set. Most of these are obvious as

to their contents by their title while others will become clearer as you enter the sections and learn about the descriptions contained within: Placement Administration Measurement and Monitoring Extracorporeal Assistance and Performance Extracorporeal Therapies Other Procedures Chiropractics Additional information about ICD-10-PCS can be found at: https://www.cms.gov/medicare/icd-10/2022-icd-10-pcs

Discussion Activities 1. Identify a root operative term from the Placement, or Other Procedures section and create a scenario using it. Include the ICD-10-PCS code used to report that procedure. (Learning Outcome: 36.1 and 36.7) 2. Explain, in your own words the difference between a procedure reported from the Extracorporeal or Systemic Assistance and Performance and those reported from the Extracorporeal or Systemic Therapies section. Include a specific example of each. (Learning Outcome: 18.2) Additional Resources AAPC: www.aapc.com American Health Information Management Association: www.ahima.org American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org Chapter 36 Review Answer Key Let’s Check It! Terminology Answer: 1. C Extracorporeal 2. E Placement 3. D Mearsurement 4. F Somatic 5. B Extra-articular 6. A Administration Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03

Learning Objective: 36.04 Learning Objective: 36.06 Learning Objective: 36.08 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Osteopathic Services Topic: Reporting Inpatient Chiropractic Services Blooms: Remember CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: Part I: Placement (2), Administration (3), Measurement & Monitoring (4) 1. Answer: A Y Feedback: Within the Placement Section - Character Position 2: Body System Anatomical Orifices are identified by character Y. Learning Objective: 36.01 Topic: Reporting Services from the Placement Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 2. Answer: C Compression Feedback: Within the Placement Section - Character Position 3: Root Operation - Putting pressure on a body region identified with character 1 is known as compression. Compression: Putting pressure on a body region … Character 1 Dressing: Putting material on a body region for protection … Character 2 Immobilization: Limiting or preventing motion of an external body region … Character 3 Packing: Putting material in a body region or orifice … Character 4

Removal: Taking out or off a device from a body part … Character 5 Traction: Exerting a pulling force on a body region in a distal direction … Character 6 Learning Objective: 36.01 Topic: Reporting Services from the Placement Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 3. Answer: B 8 Feedback: Within the Placement Section - Character Position 4: Body Regions – The Upper Extremity, Right is identified by character 8. Learning Objective: 36.01 Topic: Reporting Services from the Placement Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 4. Answer: D External Feedback: This one is easy; there is only one choice. Remember that all procedures reported from the Placement section do not involve incisions or punctures. This means all of these devices are external. External approach … Character X. Learning Objective: 36.01 Topic: Reporting Services from the Placement Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 5. Answer: B 2

Feedback: Within the Placement Section - Character Position 6: Device - The character that would identify the cast is character 2. Learning Objective: 36.01 Topic: Reporting Services from the Placement Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: C 3 Feedback: Procedures reported from the Administration Section will all begin with the section number 3. Learning Objective: 36.02 Topic: Reporting Services from the Administration Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: B C Feedback: Within the Administration Section - Character Position 2: Physiology System – An indwelling device would be identified with the character C. Learning Objective: 36.02 Topic: Reporting Services from the Administration Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: C Administration Feedback: A blood transfusion would be reported from the Administration Section - Character Position 3: Root operation character 2. Learning Objective: 36.02 Topic: Reporting Services from the Administration Section

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: A Z Feedback: Within the Administration Section - Character Position 4: Body System/Region - When an irrigating substance (eg. saline solution) is administered into an indwelling device (reported as body system Indwelling Device … C), the body system/region will be reported with the character Z None. Learning Objective: 36.02 Topic: Reporting Services from the Administration Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 10. Answer: C 8 Feedback: Within the Administration Section - Character Position 7: Qualifier – Oxazolidinones is reported with character 8. Learning Objective: 36.02 Topic: Reporting Services from the Administration Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 11. Answer: C Function/device Feedback: Character Position 1 2 3

Character Meaning Section of the ICD-10-PCS book Physiological System Root operation term

4 Body System 5 Approach used by physician 6 Function/Device 7 Qualifier, if applicable Learning Objective: 36.03 Topic: Reporting Services from the Measurement and Monitoring Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 12. Answer: C B Feedback: Within the Measurement and Monitoring Section - Character Position 2 - A physiological device would be represented with character B. Learning Objective: 36.03 Topic: Reporting Services from the Measurement and Monitoring Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 13. Answer: B monitoring. Feedback: Within the Measurement and Monitoring Section - Character Position 3: Root Operation -Monitoring: Determining the level of a physiological or physical function repetitively over a period of time … Character 1. Learning Objective: 36.03 Topic: Reporting Services from the Measurement and Monitoring Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 14.

Answer: D K Feedback: Within the Measurement and Monitoring Section - Character Position 6 – Measuring a patient‘s temperature would be reported with character K. Learning Objective: 36.03 Topic: Reporting Services from the Measurement and Monitoring Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 15. Answer: B Q Feedback: Within the Measurement and Monitoring Section Character Position 6 – A sleep study would be reported with character Q. Learning Objective: 36.03 Topic: Reporting Services from the Measurement and Monitoring Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Part II: Extracorporeal or Systemic Assistance and Performance (5), Extracorporeal or Systemic Therapies (6), Osteopathic (7), Other Procedures (8), and Chiropractic (9) Sections 1. Answer: D Function Feedback: Character Position Character Meaning 1 Section of the ICD-10-PCS book 2 Physiological System 3 Root operation term 4 Body System 5 Duration 6 Function 7 Qualifier, if applicable Learning Objective: 36.04 Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 2. Answer: B Extracorporeal Feedback: The terms meaning outside the body is known as extracorporeal • Phototherapy - treatment by light rays • Extracorporeal - Outside of the body • Extra-Articular – Outside a joint • Somatic - Related to the body, especially separate from the brain or mind Learning Objective: 36.04 Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 3. Answer: A 5 Feedback: All of the Extracorporeal or Systemic Assistance and Performance procedures will begin with the section number 5. Learning Objective: 36.04 Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 4. Answer: C manipulation. Feedback:

All of the following are root operative terms within the Extracorporeal or Systemic Assistance and Performance Section - Character Position 3: Root Operation • Assistance: Taking over a portion of a physiological function by extracorporeal means … Character 0 • Performance: Completely taking over a physiological function by extracorporeal means … Character 1 • Restoration: Returning, or attempting to return, a physiological function to its original state by extracorporeal means … Character 2 __________ Manipulation is found within the Chiropractic Section: Manual procedure that involves a directed thrust to move a joint past the physiological range of motion, without exceeding the anatomical limit … Character B Learning Objective: 36.04 Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 5. Answer: C Duration Feedback: Character Position Character Meaning 1 Section of the ICD-10-PCS book 2 Physiological Systems 3 Root operation 4 Body System 5 Duration 6 Qualifier, if applicable 7 Qualifier, if applicable Learning Objective: 36.05 Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute

6. Answer: D All of these Feedback: Within the Extracorporeal or Systemic Therapies Section Character Position 3: Root Operation - The following are root operative terms:  Atmospheric Control: Extracorporeal control of atmospheric pressure and composition … Character 0  Decompression: Extracorporeal elimination of undissolved gas from body fluids … Character 1  Electromagnetic Therapy: Extracorporeal treatment by electromagnetic rays … Character 2  Hyperthermia: Extracorporeal raising of body temperature … Character 3  Hypothermia: Extracorporeal lowering of body temperature … Character 4  Pheresis: Extracorporeal separation of blood products … Character 5  Phototherapy: Extracorporeal treatment by light rays … Character 6  Shock Wave Therapy: Extracorporeal treatment by shock waves … Character 9  Ultrasound Therapy: Extracorporeal treatment by ultrasound … Character 7  Ultraviolet Light Therapy: Extracorporeal treatment by ultraviolet light… Character 8 Learning Objective: 36.05 Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: C Musculoskeletal Feedback: Within the Extracorporeal or Systemic Therapies Section - Character Position 4: Body System – Character 3 represents the Musculoskeletal system. The specific body system being supported by these procedures are identified by the following characters  Skin … Character 0  Urinary … 1  Central nervous … 2  Musculoskeletal … 3  Circulatory … 5  None… Z Learning Objective: 36.05

Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: A 6 Feedback: Ultrasound therapies performed on the circulatory system, will utilize a Qualifier character to identify which specific vessels are being treated, as follows:  Head and neck vessels … 4  Heart … 5  Peripheral vessels … 6  Other vessels … 7  No Qualifier … Z Learning Objective: 36.05 Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: B Method Feedback: Character Position Character Meaning 1 Section of the ICD-10-PCS book 2 Anatomical Regions 3 Root operation term 4 Body Region 5 Approach 6 Method 7 Qualifier, if applicable Learning Objective: 36.06 Topic: Reporting Osteopathic Services Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2

ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 10. Answer: C 7 Feedback: All of the Osteopathic Section procedures will begin with the section number 7. Learning Objective: 36.06 Topic: Reporting Osteopathic Services Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 11. Answer: A Treatment Feedback: There is only one root operation used when reporting osteopathic services: Treatment: Manual treatment to eliminate or alleviate somatic dysfunction and related disorders … Character 0 ________ • Manipulation is found within the Chiropractic Section: Manual procedure that involves a directed thrust to move a joint past the physiological range of motion, without exceeding the anatomical limit … Character B • Electromagnetic Therapy is found within the Extracorporeal or Systemic Therapies Section: Extracorporeal treatment by electromagnetic rays … Character 2 • Phototherapy is found within the Extracorporeal or Systemic Therapies Section: Extracorporeal treatment by light rays … Character 6 Learning Objective: 36.06 Topic: Reporting Osteopathic Services Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 12. Answer: C 5

Feedback: Within the Osteopathic Section - Character Position 6: Method – The specific character that identifies Low velocity-high amplitude is 5 The specific methods that can be used by the Doctor during an Osteopathic session are as follows: • Articulatory-raising … Character 0 • Facial release … 1 • General mobilization … 2 • High velocity-low amplitude … 3 • Indirect … 4 • Low velocity-high amplitude … 5 • Lymphatic pump… 6 • Muscle energy - isometric… 7 • Muscle energy - isotonic … 8 • Other method … 9 Learning Objective: 36.06 Topic: Reporting Osteopathic Services Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 13. Answer: B 8 Feedback: All of the Other Procedure Section procedures will begin with the section number 8. Learning Objective: 36.07 Topic: Reporting from the Other Procedures Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 14. Answer: D C Feedback: Within the Other Procedure Section - Character Position 2: Physiology System – An Indwelling device is identified with character C: There are only two options for the second character: Indwelling device … Character C Physiological Systems and Anatomical Regions… Character E Learning Objective: 36.07 Topic: Reporting from the Other Procedures Section

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 15. Answer: A 7 Feedback: Within the Other Procedure Section - Character Position 5: Approach - A procedure performed Via Natural or Artificial Opening is identified with character 7 The fifth character position, reporting the approach, will provide you with the following options: Open (0), Percutaneous (3), Percutaneous Endoscopic (4), Via Natural or Artificial Opening (7), Via Natural or Artificial Opening Endoscopic (8), and External (X). Learning Objective: 36.07 Topic: Reporting from the Other Procedures Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 16. Answer: C 0 Feedback: Within the Other Procedure Section - Character Position 6: Method – An acupuncture would be identified with character 0 In character position 6, you will identify the method employed during this procedure as follows: • Acupuncture … Character 0 • Therapeutic massage … 1 • Collection … 6 • Computer Assisted Procedure … B • Robotic Assisted Procedure … C • Near infrared spectroscopy … D • Other method … Y Learning Objective: 36.07 Topic: Reporting from the Other Procedures Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 0-1 minute 17. Answer: D 9 Feedback: Procedures reported from the Chiropractic Section will all begin with the number 9. Learning Objective: 36.08 Topic: Reporting Inpatient Chiropractic Services Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 18. Answer: B W Feedback: Within the Chiropractic Section - Character Position 2: Anatomical Regions - There is only one option for the second character: Anatomical Regions which is represented with the character W. Learning Objective: 36.08 Topic: Reporting Inpatient Chiropractic Services Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 19. Answer: D External Feedback: All chiropractic services use an external approach, reported with character X. Learning Objective: 36.08 Topic: Reporting Inpatient Chiropractic Services Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 20.

Answer: C J Feedback: Within the Chiropractic Section - Character Position 6: Method – A Long and Short Lever Specific Contact will be report with character J Identify the specific method used by the Doctor during the session as follows: • Non-manual … Character B • Indirect Visceral … C • Extra-Articular … D • Direct Visceral … F • Long Lever Specific Contact … G • Short Level Specific Contact … H • Long and Short Lever Specific Contact … J • Mechanically Assisted … K • Other Method … L Learning Objective: 36.08 Topic: Reporting Inpatient Chiropractic Services Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Let’s Check It! Rules and Regulations: 1. Answer: The 7 root operation terms used in the Placement Section - Character Position 3, description and character are as follows: 1. Change: Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane … Character: 0 2. Compression: Putting pressure on a body region … Character 1 3. Dressing: Putting material on a body region for protection … Character 2 4. Immobilization: Limiting or preventing motion of an external body region … Character 3 5. Packing: Putting material in a body region or orifice … Character 4 6. Removal: Taking out or off a device from a body part … Character 5 7. Traction: Exerting a pulling force on a body region in a distal direction … Character 6 Feedback: The 7 root operation terms used in the Placement Section - Character Position 3, description and character are as follows: 1. Change: Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane … Character: 0 2. Compression: Putting pressure on a body region … Character 1

3. Dressing: Putting material on a body region for protection … Character 2 4. Immobilization: Limiting or preventing motion of an external body region … Character 3 5. Packing: Putting material in a body region or orifice … Character 4 6. Removal: Taking out or off a device from a body part … Character 5 7. Traction: Exerting a pulling force on a body region in a distal direction … Character 6 Learning Objective: 36.01 Topic: Reporting Services from the Placement Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: The exception is: When an irrigating substance (eg. saline solution) is administered into an indwelling device (reported as body system Indwelling Device … C), the body system/region will be Z None. Feedback: The exception is: When an irrigating substance (eg. saline solution) is administered into an indwelling device (reported as body system Indwelling Device … C), the body system/region will be Z None. Learning Objective: 36.02 Topic: Reporting Services from the Administration Section Blooms: Analyze CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: Within the Measurement and Monitoring Section – Character Position 3: Root Operation there are only two root operative terms used to report procedures as follows: 1. Measurement: Determining the level of a physiological or physical function at a point in time … Character 0 2. Monitoring: Determining the level of a physiological or physical function repetitively over a period of time … Character 1 Feedback:

Within the Measurement and Monitoring Section – Character Position 3: Root Operation there are only two root operative terms used to report procedures as follows: 1. Measurement: Determining the level of a physiological or physical function at a point in time … Character 0 2. Monitoring: Determining the level of a physiological or physical function repetitively over a period of time … Character 1 Learning Objective: 36.03 Topic: Reporting Services from the Measurement and Monitoring Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: Character Position 1 2 3 4 5 6 7

Character Meaning Section of the ICD-10-PCS book Physiological System Root operation term Body System Duration Function Qualifier, if applicable

Character Position 1 2 3 4 5 6 7

Character Meaning Section of the ICD-10-PCS book Physiological System Root operation term Body System Duration Function Qualifier, if applicable

Feedback:

Learning Objective: 36.04 Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: Within the Chiropractic Section – Character Position 1 is identified by the section number 9. Feedback: Within the Chiropractic Section – Character Position 1 is identified by the section number 9. Learning Objective: 36.08 Topic: Reporting Inpatient Chiropractic Services Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Practice 1. Answer: 2W10X6Z Feedback: Correct code: 2W10X6Z Index: Compression>head Character 1: Section: Placement: Character 2 Character 2: Body System: Character W Character 3: Root Operation: Character 1 Character 4: Body Part: Character 0 Character 5: Approach: Character X Character 6: Device: Character 6 Character 7: Qualifier: Character Z Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section

Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: 2Y41X5Z Feedback: Correct code: 2Y41X5Z Index: Packing>nasal Character 1: Section: Placement: Character 2 Character 2: Body System: Character Y Character 3: Root Operation: Character 4 Character 4: Body Part: Character 1 Character 5: Approach: Character X Character 6: Device: Character 5 Character 7: Qualifier: Character Z Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section

Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: 30233N1 Feedback: Correct code: 30233N1 Index: Transfusion>vein>peripheral>blood>red cells Character 1: Section: Administration: Character 3 Character 2: Body System: Character 0 Character 3: Root Operation: Character 2 Character 4: Body System/Region: Character 3 Character 5: Approach: Character 3 Character 6: Substance: Character N Character 7: Qualifier: Character 1 Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d

CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: 3E1M38Z Feedback: Correct code: 3E1M38Z Index: Irrigation>peritoneal cavity>irrigation substance Character 1: Section: Administration: Character 3 Character 2: Body System: Character E Character 3: Root Operation: Character 1 Character 4: Body System/Region: Character M Character 5: Approach: Character 3 Character 6: Substance: Character 8 Character 7: Qualifier: Character Z Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer:

4A0ZXKZ Feedback: Correct code: 4A0ZXKZ Index: Measurement>temperature Character 1: Section: Measurement and Monitoring: Character 4 Character 2: Body System: Character A Character 3: Root Operation: Character 0 Character 4: Body System: Character Z Character 5: Approach: Character X Character 6: Function/Device: Character K Character 7: Qualifier: Character Z Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 6. Answer: 4A12XM4 Feedback: Correct code: 4A12XM4 Index: Monitoring>cardiac>total activity, stress Character 1: Section: Measurement and Monitoring: Character 4 Character 2: Body System: Character A

Character 3: Root Operation: Character 1 Character 4: Body System: Character 2 Character 5: Approach: Character X Character 6: Function/Device: Character M Character 7: Qualifier: Character 4 Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: 4A19X1Z Feedback: Correct code: 4A19X1Z Index: Monitoring>respiratory>capacity Character 1: Section: Measurement and Monitoring: Character 4 Character 2: Body System: Character A Character 3: Root Operation: Character 1 Character 4: Body System: Character 9 Character 5: Approach: Character X Character 6: Function/Device: Character 1 Character 7: Qualifier: Character Z Learning Objective: 36.01

Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: 5A1955Z Feedback: Correct code: 5A1955Z Index: Performance>respiratory>greater than 96 consecutive hours, ventilation Character 1: Section: Extracorporeal or Systemic Assistance and Performance: Character 5 Character 2: Body System: Character A Character 3: Root Operation: Character 1 Character 4: Body System: Character 9 Character 5: Duration: Character 5 Character 6: Function: Character 5 Character 7: Qualifier: Character Z Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05

Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: 5A2204Z Feedback: Correct code: 5A2204Z Index: Restoration>cardiac>single>rhythm Character 1: Section: Extracorporeal or Systemic Assistance and Performance: Character 5 Character 2: Body System: Character A Character 3: Root Operation: Character 2 Character 4: Body System: Character 2 Character 5: Duration: Character 0 Character 6: Function: Character 4 Character 7: Qualifier: Character Z Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section

Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: 6A930ZZ Feedback: Correct code: 6A930ZZ Index: Shock Wave therapy, musculoskeletal Character 1: Section: Extracorporeal or Systemic Therapies: Character 6 Character 2: Body System: Character A Character 3: Root Operation: Character 9 Character 4: Body System: Character 3 Character 5: Duration: Character 0 Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section

Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: 6A210ZZ Feedback: Correct code: 6A210ZZ Index: Electromagnetic therapy>urinary Character 1: Section: Extracorporeal or Systemic Therapies: Character 6 Character 2: Body System: Character A Character 3: Root Operation: Character 2 Character 4: Body System: Character 1 Character 5: Duration: Character 0 Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: 7W03X5Z Feedback: Correct code: 7W03X5Z Index: Osteopathic treatment>lumbar Character 1: Section: Osteopathic: Character 7 Character 2: Body System: Character W Character 3: Root Operation: Character 0 Character 4: Body System: Character 3 Character 5: Approach: Character X Character 6: Method: Character 5 Character 7: Qualifier: Character Z Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes

13. Answer: 8E0H30Z Feedback: Correct code: 8E0H30Z Index: Acupuncture>integumentary system>no qualifier Character 1: Section: Other Procedures: Character 8 Character 2: Body System: Character E Character 3: Root Operation: Character 0 Character 4: Body Region: Character H Character 5: Approach: Character 3 Character 6: Method: Character 0 Character 7: Qualifier: Character Z Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14. Answer: 9WB1XKZ Feedback: Correct code: 9WB1XKZ Index: Chiropractic manipulation>cervical

Character 1: Section: Chiropractic: Character 9 Character 2: Body System: Character W Character 3: Root Operation: Character B Character 4: Body Region: Character 1 Character 5: Approach: Character X Character 6: Method: Character K Character 7: Qualifier: Character Z Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: 9WB5XJZ Feedback: Correct code: 9WB5XJZ Index: Chiropractic manipulation>pelvis Character 1: Section: Chiropractic: Character 9 Character 2: Body System: Character W Character 3: Root Operation: Character B Character 4: Body Region: Character 5 Character 5: Approach: Character X Character 6: Method: Character J

Character 7: Qualifier: Character Z Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application Application 1: NATHANSON, MYRA Answer: 3E0F73Z, 3E0333Z Feedback: 3E0F73Z: ICD-10-PCS index> Introduction of substance in or on>respiratory tract>via natural opening>anti-inflammatory>no qualifier 3E0333Z: ICD-10-PCS index> Introduction of substance in or on>vein>peripheral>percutaneous> anti-inflammatory>no qualifier For the convenience of the instructor: BB0DZZZ: ICD-10-PCS index>plain radiography>airways, upper Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05

Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: WARTTEL, JUDITH Answer: 5A05121, 5A1D70Z Feedback: 5A05121: ICD-10-PCS index>oxygenation>hyperbaric>circulatory>intermittent>oxygenation> hyperbaric 5A1D70Z: ICD-10-PCS index>performance>urinary>intermittent>less than 6 hours per day filtration Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section

Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: SHEPARD, JANIS Answer: 4A02X4Z Feedback: 4A02X4Z: ICD-10-PCS index>EKG>measurement>cardiac>external>electrical activity> no qualifier Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 3-5 minutes Application 4: KENSINGTON, CHARLES Answer: 4A00X4Z Feedback: 4A00X4Z: ICD-10-PCS index>electroencephalogram (EEG)>measurement>central nervous>external>electrical activity Learning Objective: 36.01 Learning Objective: 36.02 Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: HELMSLEY, GRAYSON Answer: 3E03305 Feedback: 3E03305: ICD-10-PCS index>introduction of substance in or on>vein>peripheral> antineoplastic>percutaneous>other antineoplastic Learning Objective: 36.01 Learning Objective: 36.02

Learning Objective: 36.03 Learning Objective: 36.04 Learning Objective: 36.05 Learning Objective: 36.06 Learning Objective: 36.07 Learning Objective: 36.08 Learning Objective: 36.09 Topic: Reporting Services from the Placement Section Topic: Reporting Services from the Administration Section Topic: Reporting Services from the Measurement and Monitoring Section Topic: Reporting from the Extracorporeal or Systemic Assistance and Performance Section Topic: Reporting Services from the Extracorporeal or Systemic Therapies Section Topic: Reporting Osteopathic Services Topic: Reporting from the Other Procedures Section Topic: Reporting Inpatient Chiropractic Services Topic: Sections 2-9; Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 37 Imaging, Nuclear Medicine, Radiation Therapy Sections 2024 Compliant Learning Outcomes

LO 37.1 Recognize the details reported from the Imaging Section. LO 37.2 Evaluate the details to determine the correct code reported from the Nuclear Medicine Section. LO 37.3 Determine the specifics required to build a code from the Radiation Therapy Section. LO 37.4 Analyze all of the details to build an accurate seven-character code for sections B, C, and D. Chapter Outline Learning Outcomes Key Terms Reporting from the Imaging Section Character Definitions Character Position 1: Imaging Section B Character Position 2: Body System Character Position 3: Root Type Character Position 4: Body Part

Character Position 5: Contrast Character Position 6: Qualifier Character Position 7: Qualifier Reporting from the Nuclear Medicine Section Character Definitions Character Position 1: Nuclear Medicine Section C Character Position 2: Body System Character Position 3: Root Type Character Position 4: Body Part Character Position 5: Radionuclide Character Position 6: Qualifier Character Position 7: Qualifier Reporting from the Radiation Therapy Section Character Definitions Character Position 1: Radiation Oncology Section D Character Position 2: Body System Character Position 3: Root Type Character Position 4: Treatment Site Character Position 5: Modality Qualifier Character Position 6: Isotope Character Position 7: Qualifier Sections B, C, and D: Putting It All Together Chapter Summary Chapter 37 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Rules and Regulations You Code It! Practice You Code It! Application

Chapter Overview The last six sections of ICD-10-PCS focus on coding for services provided by imaging professionals, rehabilitation specialists, audiologists, and mental health/behavioral health professionals. Imaging Section Nuclear Medicine Section Radiation Therapy Section Additional information about ICD-10-PCS can be found at: https://www.cms.gov/medicare/icd-10/2022-icd-10-pcs Discussion Activities 1. The root operation terms differ from those used in other sections. Identify a root operation term from the Imaging, Nuclear Medicine, or Radiation Therapy sections and create a scenario using it. Include the ICD-10-PCS code used to report that procedure. (Learning Outcome: 37.1, 37.2, and 37.3) For examples: Nuclear Medicine includes Non-imaging uptake and systemic therapy, neither of which are used in any other section. 2. Explain, in your own words, what a radionuclide is and how they are used in health care. Include a specific example of each. (Learning Outcome: 37.2) Additional Resources AAPC: www.aapc.com American Health Information Management Association: www.ahima.org American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org

Chapter 37 Review Answer Key

Let’s Check It! Terminology Answer: 7. D Low Osmolar 8. C Intravascular Optical Coherence 9. A Densitometry 10. B High Osmolar Learning Objective: 37.01 Topic: Reporting from the Imaging Section Blooms: Remember CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: B Contrast Feedback: Character Position Character Meaning 1 Section of the ICD-10-PCS book 2 Body system 3 Root Type 4 Body part (specific anatomical site) 5 Contrast, if applicable 6 Device, if applicable 7 Qualifier, if applicable Learning Objective: 37.01 Topic: Reporting from the Imaging Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 2. Answer:

BB Feedback: All of the codes reporting an imaging section procedure will begin with the section letter B. Learning Objective: 37.01 Topic: Reporting from the Imaging Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 3. Answer: C PET. Feedback: The five root types found in the Imaging Section - Character Position 3 are the type of imaging technology being used:  Plain Radiography (x-ray) … Character 0  Fluoroscopy … Character 1  Computerized Tomography (CT scan) … Character 2  Magnetic Resonance Imaging (MRI) … Character 3  Ultrasonography … Character 4 ___________  Positron Emission Tomographic (PET) Imaging - can be found within the Nuclear Medicine Section. PET is the introduction of radioactive materials into the body for three-dimensional display of images developed from the simultaneous capture, 180 degrees apart, of radioactive emissions … Character 3 Learning Objective: 37.01 Topic: Reporting from the Imaging Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 4. Answer: D All of these Feedback:

Within the Imaging Section - Character Position 6: Qualifier – The character placed in the sixth (6) position will identify an additional detail, specific to that Table. The available options are:  Unenhanced and Enhanced … Character 0  Laser … Character 1  Intravascular Optical Coherence … Character 2  None … Character Z Learning Objective: 37.01 Topic: Reporting from the Imaging Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 5. Answer: D C Feedback: All of the codes reporting a nuclear medicine section procedure will begin with the section letter C. Learning Objective: 37.02 Topic: Reporting from the Nuclear Medicine Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: A5 Feedback: Within the Nuclear Medicine Section – Character Position 5: Radionuclide – These descriptors explain the radioactive materials – the source of the radiation being used. Learning Objective: 37.02 Topic: Reporting from the Nuclear Medicine Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: D tomographic (tomo) nuclear medicine imaging. Feedback: The seven root types found in the Nuclear Medicine Section –Character Position 3 are: • Planar Nuclear Medicine Imaging: Introduction of radioactive materials into the body for single-plane display of images developed from the capture of radioactive emissions … Character 1 • Tomographic (Tomo) Nuclear Medicine Imaging: Introduction of radioactive materials into the body for three-dimensional display of images developed from the capture of radioactive emissions … Character 2 • Positron Emission Tomographic (PET) Imaging: Introduction of radioactive materials into the body for three-dimensional display of images developed from the simultaneous capture, 180 degrees apart, of radioactive emissions … Character 3 • Nonimaging Nuclear Medicine Uptake: Introduction of radioactive materials into the body for measurements of organ function, from the detection of radioactive emissions … Character 4 • Nonimaging Nuclear Medicine Probe: Introduction of radioactive materials into the body for the study of distribution and fate of certain substances by the detection of radioactive emissions; or alternatively, measurement of absorption of radioactive emissions from an external source … Character 5 • Nonimaging Nuclear Medicine Assay: Introduction of radioactive materials into the body for the study of body fluids and blood elements, by the detection of radioactive emissions … Character 6 • Systemic Nuclear Medicine Therapy: Introduction of unsealed radioactive materials into the body for treatment … Character 7 Learning Objective: 37.02 Topic: Reporting from the Nuclear Medicine Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: C3 Feedback:

Within the Radiation Oncology Section – Character Position 3: Root Types There are only four root types used to describe the modality of these procedures.  Beam Radiation: Character 0  Brachytherapy: Character 1  Stereotactic Radiosurgery: Character 2  Other Radiation: Character Y Learning Objective: 37.03 Topic: Reporting from the Radiation Therapy Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: B an isotope. Feedback: Within the Radiation Oncology Section – Character Position 6: Isotope: This character position identifies the specific radioactive substance used during this procedure. Examples are: • Cesium 137 (Cs-137) … Character 7 • Iridium 192 (Ir-192) … Character 8 • Iodine 125 (I-1250 … Character 9 • Palladium 103 (Pd-103) … Character B • Californium 252 (Cf-252) … Character C • Iodine 131 (I-131) … Character D • Phosphorus 32 (P-32) … Character F • Strontium 89 (Sr-89) … Character G • Strontium 90 (Sr-90) … Character H • Other Isotope … Character Y • None … Character Z Learning Objective: 37.03 Topic: Reporting from the Radiation Therapy Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 10. Answer:

B0 Feedback: Within the Radiation Oncology Section – Character Position 7: Qualifier – This character will report that the radiation treatment was provided during a surgical procedure – or not.  Intraoperative … Character 0  No Qualifier … Character Z Learning Objective: 37.03 Topic: Reporting from the Radiation Therapy Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Let’s Check It! Rules and Regulations: 1. Answer: The five root types found in the Imaging Section - Character Position 3 are the type of imaging technology being used:  Plain Radiography (x-ray) … Character 0  Fluoroscopy … Character 1  Computerized Tomography (CT scan) … Character 2  Magnetic Resonance Imaging (MRI) … Character 3  Ultrasonography … Character 4 Feedback: The five root types found in the Imaging Section - Character Position 3 are the type of imaging technology being used: • Plain Radiography (x-ray) … Character 0 • Fluoroscopy … Character 1 • Computerized Tomography (CT scan) … Character 2 • Magnetic Resonance Imaging (MRI) … Character 3 • Ultrasonography … Character 4 Learning Objective: 37.01 Topic: Reporting from the Imaging Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2.

Answer: This seventh character is required and may enable you to share additional details about this specific imaging procedure. The six options found in the Imaging Section – Character Position 7: Qualifier are: • Intraoperative … Character 0 • Densitometry … Character 1 • Intravascular … Character 3 • Transesophageal … Character 4 • Guidance … Character A • None … Character Z Feedback: This seventh character is required and may enable you to share additional details about this specific imaging procedure. The six options found in the Imaging Section – Character Position 7: Qualifier are: • Intraoperative … Character 0 • Densitometry … Character 1 • Intravascular … Character 3 • Transesophageal … Character 4 • Guidance … Character A • None … Character Z Learning Objective: 37.01 Topic: Reporting from the Imaging Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: When radioactive materials are used to treat malignancies, the procedure is reported from the Radiation Therapy section. Feedback: When radioactive materials are used to treat malignancies, the procedure is reported from the Radiation Therapy section.

Learning Objective: 37.03 Topic: Reporting from the Radiation Therapy Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

4. Answer: The options in this list include the descriptors of radioactive materials—the source of the radiation. Be careful—some of these are very similar. • Technetium 99m (Tc-99m) . . . Character 1 • Cobalt 58 (C0-58) . . . 7 • Samarium 153 (Sm-153) . . . 8 • Krypton (Kr-81m) . . . 9 • Carbon 11 (C-11) . . . B • Cobalt 57 (Co-57) . . . C • Indium 111 (In-111) . . . D • Iodine 123 (I-123) . . . F • Iodine 131 (I-131) . . . G • Iodine 125 (I-125) . . . H • Fluorine 18 (F-18) . . . K • Gallium 67 (Ga-67) . . . L • Oxygen 15 (O-15) . . . M • Phosphorus 32 (P-32) . . . N • Strontium 89 (Sr-89) . . . P • Rubidium 82 (Rb-82) . . . Q • Nitrogen 13 (N-13) . . . R • Thallium 201 (Tl-201) . . .S • Xenon 127 (Xe-127) . . . T • Xenon 133 (Xe-133) . . . V • Chromium (Cr-51) . . . W • Other Radionuclide . . . Y The "Other Radionuclide" option is available to report any newly approved radionuclides. It is recommended to append documentation to the claim using this character to explain the specific radiation source utilized on the patient. • None . . . Z Feedback: The options in this list include the descriptors of radioactive materials—the source of the radiation. Be careful—some of these are very similar. • Technetium 99m (Tc-99m) . . . Character 1 • Cobalt 58 (C0-58) . . . 7 • Samarium 153 (Sm-153) . . . 8 • Krypton (Kr-81m) . . . 9 • Carbon 11 (C-11) . . . B • Cobalt 57 (Co-57) . . . C • Indium 111 (In-111) . . . D • Iodine 123 (I-123) . . . F • Iodine 131 (I-131) . . . G • Iodine 125 (I-125) . . . H • Fluorine 18 (F-18) . . . K • Gallium 67 (Ga-67) . . . L • Oxygen 15 (O-15) . . . M • Phosphorus 32 (P-32) . . . N

• Strontium 89 (Sr-89) . . . P • Rubidium 82 (Rb-82) . . . Q • Nitrogen 13 (N-13) . . . R • Thallium 201 (Tl-201) . . .S • Xenon 127 (Xe-127) . . . T • Xenon 133 (Xe-133) . . . V • Chromium (Cr-51) . . . W • Other Radionuclide . . . Y The "Other Radionuclide" option is available to report any newly approved radionuclides. It is recommended to append documentation to the claim using this character to explain the specific radiation source utilized on the patient. • None . . . Z Learning Objective: 37.02 Topic: Reporting from the Nuclear Medicine Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: • Beam Radiation: Character 0 • Brachytherapy: Character 1 • Stereotactic Radiosurgery: Character 2 • Other Radiation: Character Y Feedback: • Beam Radiation: Character 0 • Brachytherapy: Character 1 • Stereotactic Radiosurgery: Character 2 • Other Radiation: Character Y Learning Objective: 37.03 Topic: Reporting from the Radiation Therapy Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Practice 1. Answer:

BQ0HZZZ Feedback: Correct code: BQ0HZZZ Index: Plain Radiography>ankle>left Character 1: Section: Imaging: Character B Character 2: Body System: Character Q Character 3: Root Type: Character 0 Character 4: Body Part: Character H Character 5: Contract: Character Z Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: BT45ZZZ Feedback: Correct code: BT45ZZZ Index: Ultrasonography>urethra Character 1: Section: Imaging: Character B Character 2: Body System: Character T Character 3: Root Type: Character 4 Character 4: Body Part: Character 5 Character 5: Contract: Character Z Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section

Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: BQ37ZZZ Feedback: Correct code: BQ37ZZZ Index: Magnetic Resonance Imaging (MRI)>knee>right Character 1: Section: Imaging: Character B Character 2: Body System: Character Q Character 3: Root Type: Character 3 Character 4: Body Part: Character 7 Character 5: Contract: Character Z Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: CG12FZZ Feedback: Correct code: CG12FZZ Index: Planar Nuclear Medicine Imaging>Gland>Thyroid Character 1: Section: Nuclear Medicine: Character C Character 2: Body System: Character G Character 3: Root Type: Character 1

Character 4: Body Part: Character 2 Character 5: Radionuclide: Character F Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: CG211ZZ Feedback: Correct code: CG211ZZ Index: Tomographic Nuclear Medicine Imaging>Gland, Parathyroid Character 1: Section: Nuclear Medicine: Character C Character 2: Body System: Character G Character 3: Root Type: Character 2 Character 4: Body Part: Character 1 Character 5: Radionuclide: Character 1 Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium

Est Time: 3-5 minutes 6. Answer: CB32KZZ Feedback: Correct code: CB32KZZ Index: Positron Emission Tomographic Imaging >Lungs and Bronchi Character 1: Section: Nuclear Medicine: Character C Character 2: Body System: Character B Character 3: Root Type: Character 3 Character 4: Body Part: Character 2 Character 5: Radionuclide: Character K Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 7. Answer: CF261ZZ

Feedback: Correct code: CF261ZZ

Index: tomographic nuclear medicine imaging>liver and spleen Character 1: Section: Nuclear Medicine: Character C Character 2: Body System: Character F Character 3: Root Type: Character 2 Character 4: Body Part: Character 6 Character 5: Radionuclide: Character Y Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03

Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 8. Answer: C23YYZZ Feedback: Correct code: C23YYZZ Index: Positron Emission Tomographic (PET) Imaging>heart Character 1: Section: Nuclear Medicine: Character C Character 2: Body System: Character 2 Character 3: Root Type: Character 3 Character 4: Body Part: Character Y Character 5: Radionuclide: Character Y Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 9. Answer: CW7NPZZ Feedback: Correct code: CW7NPZZ

Index: System nuclear medicine therapy>whole body Character 1: Section: Nuclear Medicine: Character C Character 2: Body System: Character W Character 3: Root Type: Character 7 Character 4: Body Part: Character N Character 5: Radionuclide: Character P Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 10. Answer: DD001ZZ Feedback: Correct code: DD001ZZ Index: Radiation Therapy>beam radiation>esophagus Character 1: Section: Radiation Oncology: Character D Character 2: Body System: Character D Character 3: Modality: Character 0 Character 4: Treatment Site: Character 0 Character 5: Modality Qualifier: Character 1 Character 6: Isotope: Character Z Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 11. Answer: D718B8Z Feedback: Correct code: D718B8Z Index: Radiation Therapy>brachytherapy>lymphatics>inguinal Character 1: Section: Radiation Oncology: Character D Character 2: Body System: Character 7 Character 3: Modality: Character 1 Character 4: Treatment Site: Character 8 Character 5: Modality Qualifier: Character B Character 6: Isotope: Character 8 Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 12. Answer: D820JZZ Feedback: Correct code: D820JZZ Index: Sterotactic Radiosurgery>Gamma Beam>Eye Character 1: Section: Radiation Oncology: Character D Character 2: Body System: Character 8 Character 3: Modality: Character 2 Character 4: Treatment Site: Character 0 Character 5: Modality Qualifier: Character J Character 6: Isotope: Character Z

Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 13. Answer: D913B9Z Feedback: Correct code: D913B9Z Index: Brachytherapy>hypopharynx Character 1: Section: Radiation Oncology: Character D Character 2: Body System: Character 9 Character 3: Modality: Character 1 Character 4: Treatment Site: Character 3 Character 5: Modality Qualifier: Character B Character 6: Isotope: Character 9 Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 14.

Answer: DB22HZZ Feedback: Correct code: DB22HZZ Index> stereotactic radiosurgery>lung Character 1: Section: Radiation Oncology: Character D Character 2: Body System: Character B Character 3: Modality: Character 2 Character 4: Treatment Site: Character 2 Character 5: Modality Qualifier: Character H Character 6: Isotope: Character Z Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 15. Answer: DP092ZZ Feedback: Correct code: DP092ZZ Index: Beam Radiation>femur Character 1: Section: Radiation Oncology: Character D Character 2: Body System: Character P Character 3: Modality: Character 0 Character 4: Treatment Site: Character 9 Character 5: Modality Qualifier: Character 2 Character 6: Isotope: Character Z Character 7: Qualifier: Character Z Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section

Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes You Code It! Application Application 1: ALTERMANN, AMANDA Answer: BN00ZZZ, B030ZZZ Feedback: BN00ZZZ: ICD-10-PCS Manual>index>plain radiography>skull>no contrast>no qualifier>no qualifier B030ZZZ: ICD-10-PCS Manual>index>MRI>brain>without contract>no qualifier>no qualifier Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: GRIFFTH, KERRAN Answer: BT1D1ZZ Feedback: BT1D1ZZ: ICD-10-PCS>pyelography sends you to fluoroscopy, urinary system Fluoroscopy>kidney>ureter and bladder>right Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03

Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: LACTANA, LAVINIA Answer: DM109BZ, DM119BZ Feedback: DM109BZ: ICD-10-PCS index> brachytherapy>left breast>high dose>Palladium 103 DM119BZ: ICD-10-PCS index> brachytherapy> right breast>high does>Palladium 103 Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: HARRINGTON, ROSA Answer: BD48ZZZ Feedback: BD48ZZZ: ICD-10-PCS Manual>index>ultrasonography>appendix Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03

Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: WAYFIELD, PORTER Answer: BR00ZZZ, BR09ZZZ Feedback: BR00ZZZ: ICD-10-PCS Manual>index>imaging, diagnostic>see plain radiography>spine> cervical>no device>no qualifier. BR09ZZZ: ICD-10-PCS Manual>index>imaging, diagnostic>see plain radiography>spine> lumbar>no device>no qualifier. Learning Objective: 37.01 Learning Objective: 37.02 Learning Objective: 37.03 Learning Objective: 37.04 Topic: Reporting from the Imaging Section Topic: Reporting from the Nuclear Medicine Section Topic: Reporting from the Radiation Therapy Section Topic: Sections B, C, and D: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 38 Physical Rehabilitation Thru New Technology Sections (FX) 2024 Compliant Learning Outcomes

LO 38.1 Recognize the details reported from the Physical Rehabilitation and Diagnostic Audiology Section. LO 38.2 Evaluate the details to determine services reported from the Mental Health Section.

LO 38.3 Determine the specifics required to accurately report services from the Substance Abuse Treatment Section. LO 38.4 Interpret the documentation to report services from the New Technology Section. LO 38.5 Analyze documentation to report ICD-10-PCS codes from sections F–X. Chapter Outline Learning Outcomes Key Terms Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Character Definitions Character Position 1: Physical Rehabilitation and Diagnostic Audiology Section F Character Position 2: Section Qualifier Character Position 3: Root Type Character Position 4: Body System & Region Character Position 5: Type Qualifier Character Position 6: Equipment Character Position 7: Qualifier Reporting Services from the Mental Health Section Character Definitions Character Position 1: Mental Health Section G Character Position 2: Body System Character Position 3: Root Type Character Position 4: Type Qualifier Character Position 5: Qualifier Character Position 6: Qualifier Character Position 7: Qualifier Reporting from the Substance Abuse Treatment Section Character Definitions Character Position 1: Substance Abuse Section H Character Position 2: Body Systems Character Position 3: Root Type Character Position 4: Type Qualifier Character Position 5: Qualifier Character Position 6: Qualifier Character Position 7: Qualifier Reporting from the New Technology Section Character Definitions Character Position 1: New Technology Section X Character Position 2: Body System Being Treated Character Position 3: Root Operation Character Position 4: Body Part Character Position 5: Approach Character Position 6: Device/Substance/Technology Character Position 7: Qualifier Sections F-X: Putting It All Together Chapter Summary Chapter 38 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Rules and Regulations You Code It! Practice You Code It! Application

Chapter Overview The last sections of ICD-10-PCS focus on coding for services provided by imaging professionals, rehabilitation specialists, audiologists, and mental health/behavioral health professionals. Physical Rehabilitation and Diagnostic Audiology Section Mental Health Section Substance Abuse Treatment Section New Technology Section Additional information about ICD-10-PCS can be found at: https://www.cms.gov/medicare/icd-10/2022-icd-10-pcs Discussion Activities 2. Choose one root operation terms from the Physical Rehabilitation and Diagnostic Audiology sections and do research with a credible source to understand what the procedure or service is so you can explain it in your own words. Then, create a scenario using it and include medical necessity. Include the ICD-10-PCS code used to report that procedure. (Learning Outcome: 38.2 and 38.3) 2. Explain, in your own words, the difference between a procedure reported from the Mental Health section and the Substance Abuse sections. Include a specific example of each. (Learning Outcome: 38.1) Additional Resources AAPC: www.aapc.com American Health Information Management Association: www.ahima.org American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org

New Technology Codes for COVID-19 [C head] For 2021, newly added ICD-10-PCS procedure codes describe the introduction or infusion of both COVID-19 treatments and vaccinations, including monoclonal antibodies, provided to inpatients. Details on submitting claims to Medicare for the administration of COVID-19 vaccine to an inpatient, current information can be found at: https://www.cms.gov/medicare/covid-19/medicare-billing-covid-19-vaccine-shotadministration. It is important to check with each individual third-party payer for their own directions. As you read the individual code descriptions, you can the anatomical location of introduction, as well as the specific substance, are identified. The new ICD-10-PCS procedure codes in the 2021 code set are:

ICD-10-PCS Code

Description

XW013H6

Introduction of other new technology monoclonal antibody into subcutaneous tissue, percutaneous approach, new technology group 6

XW013K6

Introduction of leronlimab monoclonal antibody into subcutaneous tissue, percutaneous approach, new technology group 6

XW013S6

Introduction of COVID-19 vaccine dose 1 into subcutaneous tissue, percutaneous approach, new technology group 6

XW013T6

Introduction of COVID-19 vaccine dose 2 into subcutaneous tissue, percutaneous approach, new technology group 6

XW013U6

Introduction of COVID-19 vaccine into subcutaneous tissue, percutaneous approach, new

technology group 6 XW023S6

Introduction of COVID-19 vaccine dose 1 into muscle, percutaneous approach, new technology group 6

XW023T6

Introduction of COVID-19 vaccine dose 2 into muscle, percutaneous approach, new technology group 6

XW023U6

Introduction of COVID-19 vaccine into muscle, percutaneous approach, new technology group 6

XW033E6

Introduction of etesevimab monoclonal antibody into peripheral vein, percutaneous approach, new technology group 6

XW033F6

Introduction of bamlanivimab monoclonal antibody into peripheral vein, percutaneous approach, new technology group 6

XW033G6

Introduction of REGN-COV2 monoclonal antibody into peripheral vein, percutaneous approach, new technology group 6

XW033H6

Introduction of other new technology monoclonal antibody into peripheral vein, percutaneous approach, new technology group 6

XW033L6

Introduction of CD24Fc immunomodulator into peripheral vein, percutaneous approach, new technology group 6

XW043E6

Introduction of etesevimab monoclonal antibody into central vein, percutaneous approach, new technology group 6

XW043F6

Introduction of bamlanivimab monoclonal antibody into central vein, percutaneous approach, new technology group 6

XW043G6

Introduction of REGN-COV2 monoclonal antibody into central vein, percutaneous approach, new technology group 6

XW043H6

Introduction of other new technology monoclonal antibody into central vein, percutaneous approach, new technology group 6

XW043L6

Introduction of CD24Fc immunomodulator into central vein, percutaneous approach, new technology group 6

XW0DXM6

Introduction of baricitinib into mouth and pharynx, external approach, new technology group 6

XW0G7M6

Introduction of baricitinib into upper GI, via natural or artificial opening, new technology group 6

XW0H7M6

Introduction of baricitinib into lower GI, via natural or artificial opening, new technology group 6

Chapter 38 Review Answer Key

Let’s Check It! Terminology

Answer: 1. C Biofeedback 2. E Psychotherapy 3. A Abuse 4. F Rehabilitation 5. B Audiology 6. D Detoxification Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section

Blooms: Remember CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute

Let’s Check It! Concepts: 1. Answer: C Equipment Feedback: Character Position Character Meaning 1 Section of the ICD-10-PCS book 2 Section Qualifier 3 Root Type 4 Body System & Region 5 Type Qualifier 6 Equipment 7 Qualifier Learning Objective: 38.01 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 2.

Answer: B 1 Feedback: Within the Physical Rehabilitation and Diagnostic Audiology Section - Character Position 2: Section Qualifier – Characters 1 represent Diagnostic Audiology. There are only two options for the second character: • Rehabilitation … Character 0 • Diagnostic Audiology … Character 1 Learning Objective: 38.01 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 3. Answer: D 4 Feedback: Within the Physical Rehabilitation and Diagnostic Audiology Section - Character Position 3: Root Type – The character 4 represent a Hearing Aid Assessment. The root type terms are unique to report procedures in this section. • Speech Assessment … Character 0 • Monitor and/or Nerve Function Assessment … Character 1 • Activities of Daily Living Assessment … Character 2 • Hearing Assessment… Character 3 • Hearing Aid Assessment… Character 4 • Vestibular Assessment … Character 5 • Speech Treatment … Character 6 • Motor Treatment … Character 7 • Activities of Daily Living Treatment … Character 8 • Hearing Treatment … Character 9 • Cochlear Implant Treatment … Character B • Vestibular Treatment … Character C • Device Fitting … Character D • Caregiver Training … Character F Learning Objective: 38.01 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 0-1 minute 4. Answer: A G Feedback: All of the codes reporting a Mental Health section encounter will begin with the section letter G. Learning Objective: 38.02 Topic: Reporting Services from the Mental Health Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 5. Answer: B individual psychotherapy. Feedback: Within the Mental Health Section - The encounter documents: Includes behavior, cognitive, interactive, interpersonal, psychoanalysis, psychodynamic, psychophysiological, and/or supportive, identified by the Character 5 is known as Individual Psychotherapy. The 12 Mental Health Section - Character Position 3: Root Type options are:  Psychological tests: Include developmental, intellectual, psychoeducational, neurobehavioral, cognitive, neuropsychological, personality, and/or behavioral testing …. Character 1  Crisis Intervention: Includes defusing, debriefing, counseling, psychotherapy, and/or coordination of care with other providers or agencies … Character 2  Medication Management … Character 3  Individual Psychotherapy: Includes behavior, cognitive, interactive, interpersonal, psychoanalysis, psychodynamic, psychophysiological, and/or supportive … Character 5  Counseling: Exploration of vocational interest, aptitudes, and required adaptive behavior skills to develop and carry out a plan for achieving a successful vocational placement, enhancing work-related adjustment, and/or pursuing viable options in training education or preparation … Character 6  Family Psychotherapy: Remediation of emotional or behavioral problems presented by one or more family members when psychotherapy with more than one family member is indicated … Character 7  Electroconvulsive Therapy: Includes appropriate sedation and other preparation of the individual … Character B  Biofeedback: Includes electroencephalogram (EEG), blood pressure, skin temperature, or peripheral blood flow, electrocardiogram (ECG),

electrooculogram, electromyogram (EMG), respirometry or capnometry, galvanic skin response (GSR) or electrodermal response (EDR), perineometry to monitor and regulate bowel or bladder activity and electrogastrogram to monitor and regulate gastric motility … Character C  Hypnosis … Character F  Narcosynthesis … Character G  Group Psychotherapy … Character H  Light Therapy … Character J Learning Objective: 38.02 Topic: Reporting Services from the Mental Health Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 6. Answer: C 4 Feedback: Within the Mental Health Section - Character Position 4: Type Qualifier – This character position explains whether the procedure was educational or vocational, providing more detail about the encounter. Learning Objective: 38.02 Topic: Reporting Services from the Mental Health Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 7. Answer: B H Feedback: All of the codes reporting a Substance Abuse section procedure will begin with the section letter H. Learning Objective: 38.03 Topic: Reporting from the Substance Abuse Treatment Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 0-1 minute 8. Answer: D detoxification services. Feedback: Within the Substance Abuse Sections - The encounter documents: Not a treatment modality but helps the patient stabilize physically and psychologically until the body becomes free of drugs and the effects of alcohol, represented by the character 2 is known as Detoxification Services. The seven Substance Abuse Section - Character Position 3: Root Type terms used to report procedures are as follows:  Detoxification Services: Not a treatment modality but helps the patient stabilize physically and psychologically until the body becomes free of drugs and the effects of alcohol… Character 2  Individual Counseling: Comprising several techniques, which apply various strategies to address drug addiction… Character 3  Group Counseling: Provides structured group counseling sessions and healing power through the connection with others … Character 4  Individual Psychotherapy: … Character 5  Family Counseling: Provides support and education for family members of addicted individuals. Family member participation seen as critical to substance abuse treatment … Character 6  Medication Management: … Character 8  Pharmacotherapy: … Character 9 Learning Objective: 38.03 Topic: Reporting from the Substance Abuse Treatment Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute 9. Answer: A 4 Feedback: Within the Substance Abuse Section - Character Position 4: Type Qualifier – This character position will add detail to the description of the Root Type. Examples:  12-Step … Character 3 for Root Type: Individual Counseling  Interactive … Character 5 for Root Type: Individual Psychotherapy  Nicotine Replacement … Character 0 for Root Type: Pharmacotherapy Learning Objective: 38.03 Topic: Reporting from the Substance Abuse Treatment Section Blooms: Apply

CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: B X. Feedback: The codes reported from the New Technology section [X] are used to identify a specific procedure and begin with the letter X. Learning Objective: 38.04 Topic: Reporting from the New Technology Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 0-1 minute Let’s Check It! Rules and Regulations: 1. Answer: The Physical Rehabilitation and Diagnostic Audiology Section - Character Position 2: Section Qualifier - There are only two options for the second character as follows: • Rehabilitation … Character 0 • Diagnostic Audiology … Character 1 Feedback: The Physical Rehabilitation and Diagnostic Audiology Section - Character Position 2: Section Qualifier - There are only two options for the second character as follows: • Rehabilitation … Character 0 • Diagnostic Audiology … Character 1 Learning Objective: 38.01 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

2. Answer: Within the Physical Rehabilitation and Diagnostic Audiology Section - Character Position 4: Body System and Region – If the encounter is for caregiver training, the correct character assignment would be None …Character Z. Feedback: Within the Physical Rehabilitation and Diagnostic Audiology Section - Character Position 4: Body System and Region – If the encounter is for caregiver training, the correct character assignment would be None …Character Z. Learning Objective: 38.01 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: The 12 Mental Health Section - Character Position 3: Root Type options are: • Psychological tests: Include developmental, intellectual, psychoeducational, neurobehavioral, cognitive, neuropsychological, personality, and/or behavioral testing …. Character 1 • Crisis Intervention: Includes defusing, debriefing, counseling, psychotherapy, and/or coordination of care with other providers or agencies … Character 2 • Medication Management … Character 3 • Individual Psychotherapy: Includes behavior, cognitive, interactive, interpersonal, psychoanalysis, psychodynamic, psychophysiological, and/or supportive … Character 5 • Counseling: Exploration of vocational interest, aptitudes, and required adaptive behavior skills to develop and carry out a plan for achieving a successful vocational placement, enhancing work-related adjustment, and/or pursuing viable options in training education or preparation … Character 6 • Family Psychotherapy: Remediation of emotional or behavioral problems presented by one or more family members when psychotherapy with more than one family member is indicated … Character 7 • Electroconvulsive Therapy: Includes appropriate sedation and other preparation of the individual … Character B • Biofeedback: Includes electroencephalogram (EEG), blood pressure, skin temperature, or peripheral blood flow, electrocardiogram (ECG), electrooculogram, electromyogram (EMG), respirometry or capnometry, galvanic skin response (GSR) or electrodermal response (EDR), perineometry

to monitor and regulate bowel or bladder activity and electrogastrogram to monitor and regulate gastric motility … Character C • Hypnosis … Character F • Narcosynthesis … Character G • Group Psychotherapy … Character H • Light Therapy … Character J Feedback: The 12 Mental Health Section - Character Position 3: Root Type options are: • Psychological tests: Include developmental, intellectual, psychoeducational, neurobehavioral, cognitive, neuropsychological, personality, and/or behavioral testing …. Character 1 • Crisis Intervention: Includes defusing, debriefing, counseling, psychotherapy, and/or coordination of care with other providers or agencies … Character 2 • Medication Management … Character 3 • Individual Psychotherapy: Includes behavior, cognitive, interactive, interpersonal, psychoanalysis, psychodynamic, psychophysiological, and/or supportive … Character 5 • Counseling: Exploration of vocational interest, aptitudes, and required adaptive behavior skills to develop and carry out a plan for achieving a successful vocational placement, enhancing work-related adjustment, and/or pursuing viable options in training education or preparation … Character 6 • Family Psychotherapy: Remediation of emotional or behavioral problems presented by one or more family members when psychotherapy with more than one family member is indicated … Character 7 • Electroconvulsive Therapy: Includes appropriate sedation and other preparation of the individual … Character B • Biofeedback: Includes electroencephalogram (EEG), blood pressure, skin temperature, or peripheral blood flow, electrocardiogram (ECG), electrooculogram, electromyogram (EMG), respirometry or capnometry, galvanic skin response (GSR) or electrodermal response (EDR), perineometry to monitor and regulate bowel or bladder activity and electrogastrogram to monitor and regulate gastric motility … Character C • Hypnosis … Character F • Narcosynthesis … Character G • Group Psychotherapy … Character H • Light Therapy … Character J Learning Objective: 38.02 Topic: Reporting Services from the Mental Health Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

4. Answer: Within the Mental Health Section - Character Position 4: Type Qualifier – This character position explains whether the procedure was educational or vocational, providing more detail about the encounter. Feedback: Within the Mental Health Section - Character Position 4: Type Qualifier – This character position explains whether the procedure was educational or vocational, providing more detail about the encounter. Learning Objective: 38.03 Topic: Reporting from the Substance Abuse Treatment Section Blooms: Understand CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 5. Answer: The six devices described in the New technology section character position 6 are new and different than those most of us have encountered: • Blinatumomab Antineoplastic Immunotherapy … character 5... This is used for the treatment of patients with Philadelphia chromosome-negative relapsed or refractory B-cell precursor acute lymphoblastic leukemia. • Ceftazidime-Avibactam Anti-infective … character 2... This is provided for the treatment of adult patients with complicated intra-abdominal infections and complicated urinary tract infections including pyelonephritis caused by designated susceptible bacteria, including certain Enterobacteriaceae and Pseudomonas aeruginosa. • Idarucizumab, Dabigatran Reversal Agent … character 3... Idarucizumab is an antibody fragment that was developed to reverse the anticoagulant effects of dabigatran (Pradaxa). • Intraoperative Knee Replacement Sensor … character 2... Intraoperative sensors is a disposable tibial insert used to aid orthopedic surgeons in placing prosthetic joint components during knee replacement surgery. 1. Isavuconazole Anti-infective … character 4... This is used for the treatment of invasive Aspergillosis and treatment of invasive mucormycosis in patients 18 years and older. • Orbital Atherectomy Technology … character 6 ... Orbital atherectomy is used to treat patients with severely calcified coronary lesions as well as symptomatic peripheral arterial disease (PAD) within the major and branch arteries of the leg. The FDA also cleared the orbital atherectomy system (OAS) to treat stenosis in synthetic arteriovenous shunts that are often used to provide vascular access for dialysis patients. Feedback:

The six devices described in the New technology section character position 6 are new and different than those most of us have encountered: • Blinatumomab Antineoplastic Immunotherapy … character 5... This is used for the treatment of patients with Philadelphia chromosome-negative relapsed or refractory B-cell precursor acute lymphoblastic leukemia. • Ceftazidime-Avibactam Anti-infective … character 2... This is provided for the treatment of adult patients with complicated intra-abdominal infections and complicated urinary tract infections including pyelonephritis caused by designated susceptible bacteria, including certain Enterobacteriaceae and Pseudomonas aeruginosa. • Idarucizumab, Dabigatran Reversal Agent … character 3... Idarucizumab is an antibody fragment that was developed to reverse the anticoagulant effects of dabigatran (Pradaxa). • Intraoperative Knee Replacement Sensor … character 2... Intraoperative sensors is a disposable tibial insert used to aid orthopedic surgeons in placing prosthetic joint components during knee replacement surgery. 1. Isavuconazole Anti-infective … character 4... This is used for the treatment of invasive Aspergillosis and treatment of invasive mucormycosis in patients 18 years and older. • Orbital Atherectomy Technology … character 6 ... Orbital atherectomy is used to treat patients with severely calcified coronary lesions as well as symptomatic peripheral arterial disease (PAD) within the major and branch arteries of the leg. The FDA also cleared the orbital atherectomy system (OAS) to treat stenosis in synthetic arteriovenous shunts that are often used to provide vascular access for dialysis patients. Learning Objective: 38.04 Topic: Reporting from the New Technology Section Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

You Code It! Practice 1. Answer: F00ZHZZ Feedback: Correct code: F00ZHZZ Index: Speech Assessment Character 1: Section: Physical Rehabilitation and Diagnostic Audiology: Character F

Character 2: Section Qualifier: Character 0 Character 3: Root Type: Character 0 Character 4: Body System: Character Z Character 5: Type Qualifier: Character H Character 6: Equipment: Character Z Character 7: Qualifier: Character Z Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 2. Answer: F02Z4FZ Feedback: Correct code: F02Z4FZ Index: Activities of Daily Living Assessment Character 1: Section: Physical Rehabilitation and Diagnostic Audiology: Character F Character 2: Section Qualifier: Character 0 Character 3: Root Type: Character 2 Character 4: Body System: Character Z Character 5: Type Qualifier: Character 4 Character 6: Equipment: Character F Character 7: Qualifier: Character Z Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section

Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: F0BZ09Z Feedback: Correct code: F0BZ09Z Index: Cochlear Implant treatment Character 1: Section: Physical Rehabilitation and Diagnostic Audiology: Character F Character 2: Section Qualifier: Character 0 Character 3: Root Type: Character B Character 4: Body System: Character Z Character 5: Type Qualifier: Character 0 Character 6: Equipment: Character 9 Character 7: Qualifier: Character Z Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: F0DZ0ZZ

Feedback: Correct code: F0DZ0ZZ Index: Device fitting Character 1: Section: Physical Rehabilitation and Diagnostic Audiology: Character F Character 2: Section Qualifier: Character 0 Character 3: Root Type: Character D Character 4: Body System: Character Z Character 5: Type Qualifier: Character 0 Character 6: Equipment: Character Z Character 7: Qualifier: Character Z Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: GZ53ZZZ Feedback: Correct code: GZ53ZZZ Index: Psychotherapy>individual>mental health>interpersonal Character 1: Section: Mental Health: Character G Character 2: Section Qualifier: Character Z Character 3: Root Type: Character 5 Character 4: Qualifier: Character 3 Character 5: Qualifier: Character Z Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04

Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 6. Answer: GZ72ZZZ Feedback: Correct code: GZ72ZZZ Index: Psychotherapy>family, mental health services Character 1: Section: Mental Health: Character G Character 2: Section Qualifier: Character Z Character 3: Root Type: Character 7 Character 4: Qualifier: Character 2 Character 5: Qualifier: Character Z Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

7. Answer: GZ14ZZZ Feedback: Correct code: GZ14ZZZ Index: Psychological tests>cognitive status Character 1: Section: Mental Health: Character G Character 2: Section Qualifier: Character Z Character 3: Root Type: Character 1 Character 4: Qualifier: Character 4 Character 5: Qualifier: Character Z Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 8. Answer: HZ2ZZZZ Feedback: Correct code: HZ2ZZZZ Index: Detoxification Services, for substance abuse Character 1: Section: Mental Health: Character H Character 2: Section Qualifier: Character Z Character 3: Root Type: Character 2 Character 4: Qualifier: Character Z Character 5: Qualifier: Character Z Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 38.01 Learning Objective: 38.02

Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 9. Answer: HZ80ZZZ Feedback: Correct code: HZ80ZZZ Index: Medication Management>for substance abuse>Nicotine Replacement Character 1: Section: Mental Health: Character H Character 2: Section Qualifier: Character Z Character 3: Root Type: Character 2 Character 4: Qualifier: Character Z Character 5: Qualifier: Character Z Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 3-5 minutes 10. Answer: HZ53ZZZ Feedback: Correct code: HZ53ZZZ Index: Psychotherapy>individual>for substance abuse>12-step Character 1: Section: Mental Health: Character H Character 2: Section Qualifier: Character Z Character 3: Root Type: Character 2 Character 4: Qualifier: Character Z Character 5: Qualifier: Character Z Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 11. Answer: HZ4CZZZ Feedback: Correct code: HZ4CZZZ Index: Counseling>group>Infectious Disease>Post-test Character 1: Section: Mental Health: Character H Character 2: Section Qualifier: Character Z Character 3: Root Type: Character 2 Character 4: Qualifier: Character Z Character 5: Qualifier: Character Z Character 6: Qualifier: Character Z Character 7: Qualifier: Character Z

Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 12. Answer: X2A5312 Feedback: Correct code: X2A5312 Index: New Technology>cerebral embolic filtration, dual filter Note: the approach ―percutaneous‖ has been added to the case study in Connect. The student may query instructor if use textbook to code case study. Character 1: Section: Mental Health: Character X Character 2: Section Qualifier: Character 2 Character 3: Root Type: Character A Character 4: Qualifier: Character 5 Character 5: Qualifier: Character 3 Character 6: Qualifier: Character 1 Character 7: Qualifier: Character 2 Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2

CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 13. Answer: X27H3C5 Feedback: Correct code: X27H3C5 Index: New technology>dilation>Femoral>right>sustained release drug-eluting intraluminal device Character 1: Section: Mental Health: Character X Character 2: Section Qualifier: Character 2 Character 3: Root Type: Character 7 Character 4: Qualifier: Character H Character 5: Qualifier: Character 3 Character 6: Qualifier: Character C Character 7: Qualifier: Character 5 Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 14. Answer: XRGB0R7 Feedback: Correct code: XRGB0R7 XRGB0R7: Index: New technology>Fusion>Lumbar>interbody fusion device>customizable Character 1: Section: Mental Health: Character X Character 2: Section Qualifier: Character W Character 3: Root Type: Character 0

Character 4: Qualifier: Character 3 Character 5: Qualifier: Character 3 Character 6: Qualifier: Character 4 Character 7: Qualifier: Character 1 Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 15. Answer: XNS4032 Feedback: Correct code: XNS4032 Index: New Technology>reposition> thoracic, magnetically controlled growth rod(s) Character 1: Section: Mental Health: Character X Character 2: Section Qualifier: Character W Character 3: Root Type: Character 0 Character 4: Qualifier: Character 3 Character 5: Qualifier: Character 3 Character 6: Qualifier: Character 4 Character 7: Qualifier: Character 1 Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section

Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Application Application 1: HOUGH, BETH Answer: XW033A6

Feedback: XW033A6: ICD-10-PCS index> Cefiderocol Anti-infective>peripheral vein>percutaneous

Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: GILLINS, MARTIN Answer: F0FZ9ZZ Feedback: F0FZ9ZZ: Index: Caregiver training Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05

Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: WRIGHT, ROBBIN Answer: HZ31ZZZ, HZ41ZZZ Feedback: HZ31ZZZ: ICD-10-PCS>counseling>individual>behavioral HZ41ZZZ: ICD-10-PCS>counseling>group>behavioral Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: LEWTER, GENE Answer: F0125ZZ Feedback: F0125ZZ: ICD-10-PCS index>motor function assessment>neurological system - lower back/ lower extremity>range of motion and joint integrity

Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: JETT, JAMES Answer: GZ14ZZZ Feedback: GZ14ZZZ: ICD-10-PCS index>psychological test>cognitive status Learning Objective: 38.01 Learning Objective: 38.02 Learning Objective: 38.03 Learning Objective: 38.04 Learning Objective: 38.05 Topic: Reporting Services from the Physical Rehabilitation and Diagnostic Audiology Section Topic: Reporting Services from the Mental Health Section Topic: Reporting from the Substance Abuse Treatment Section Topic: Reporting from the New Technology Section Topic: Sections F-X: Putting It All Together Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

Chapter 39 Inpatient Coding Capstone 2024 Compliant Learning Outcomes LO 39.1 Correctly abstract patient records to determine accurate coding using ICD-10-CM and ICD-10-PCS code sets. Chapter Overview Reporting the procedures provided to a patient who has been admitted into an inpatient facility can cover a broad spectrum. The cases in this chapter will support student’s learning using ICD-10-PCS procedure codes. Remind them to read carefully and completely.

Additional Resources Grey’s Anatomy Online: http://www.bartleby.com/107/ MedlinePlus Medical Encyclopedia: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html Stedman’s Medical Dictionary: http://www.stedmans.com/ AAPC: http://www.aapc.com American Health Information Management Association: http://www.ahima.org American Hospital Association: http://www.aha.org

American Medical Association: http://www.ama-assn.org ICD-10-PCS: https://www.cms.gov/medicare/icd-10/2022-icd-10-pcs Chapter 39 Answer Key

CASE STUDY #1: NESTOR GONZALEZ Answer: 3E03329, BW03ZZZ, J0744x2 Feedback: 3E03329 - Alphabetic Index>Introduction of substance in or on>vein>peripheral> Percutaneous>anti-infective>Other anti-infective BW03ZZZ - Alphabetic Index>Plain Radiology>Chest

J0744x2 - Table of Drugs and Biologicals>Ciprofloxacin for Intravenous Infusion>200mg> IV Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes CASE STUDY #2: TINA LEBROCK

Answer: 027035Z Feedback: 027035Z: Alphabetic Index>Dilation>Artery>Coronary>one

Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes CASE STUDY #3: GRAYSON CARLYLE Answer: 0SHD04Z Feedback: 0SHD04Z - Alphabetic Index>Insertion>joint>knee>left>open>internal fixation device Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes CASE STUDY #4: DAMARIS ALBAQSHI Answer: 0QBG0ZZ Feedback: 0QTG0ZZ - Alphabetic Index>Excision>Tibia, right>Open>No device>No qualifier Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard

Est Time: 3-5 minutes CASE STUDY #5: MICHAEL DEMARCO Answer: 4A00X4Z Feedback: 4A00X4Z - Alphabetic Index>EEG (electroencephalogram) see Measurement, Central Nervous Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes CASE STUDY #6: POPPY BROWNING Answer: BW40ZZZ, BF100ZZ, J1885x6, J2185x30 Feedback: BW40ZZZ - Alphabetic Index>Ultrasonography>Abdomen BF100ZZ - Alphabetic Index>ERCP (endoscopic retrograde cholangiopancreatography)> see Fluoroscopy, Hepatobiliary System and Pancreas J1885x6 - Table of Drugs and Biologicals>Ketorolac tromethamine>15mg>IM, IV J2185x30 - Table of Drugs and Biologicals>Meropenem>100mg>IV> Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes CASE STUDY #7: DAVID CHANG Answer: 0TB04ZX, 0TB14ZX, 3E0D73Z, J7510 Feedback:

0TB04ZX - Alphabetic Index>Excision>Kidney>Right 0TB14ZX - Alphabetic Index>Excision>Kidney>Left 3E0D73Z - Alphabetic Index>Introduction>mouth>Anti-inflammatory

J7510 - Table of Drugs and Biologicals>Prednisolone>5mg>Oral Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes CASE STUDY #8: MARYBELLE OSENKOWSKY Answer: 3E033NZ, J1630x6 Feedback: 3E033NZ - Alphabetic Index>introduction of substance in or on>vein>peripheral> analgesics, hypnotics, sedatives J1630x6 - Table of Drugs and Biologicals>Haloperidol>5mg>IM, IV Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes CASE STUDY #9: ROGER WESTERMAN Answer: 00H002Z Feedback: 00H002Z - Alphabetic Index>Insertion of device in>Brain Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

CASE STUDY #10: KARL ATTENDA Answer: 0YQA4ZZ Feedback: 0YQA4ZZ- Alphabetic Index>repair>inguinal region>bilateral Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes CASE STUDY #11: KEASHA FROENMAN Answer: 0RQK4ZZ Feedback: 0RQK4ZZ Alphabetic Index>repair>joint>shoulder>left Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes CASE STUDY #12: REISHICA DECLERQUE Answer: 10D00Z1, 0UL70ZZ Feedback: 10D00Z1 - Alphabetic Index>extraction>products of conception>low cervical 0UL70ZZ Alphabetic Index>occlusion>fallopian tubes, bilateral Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1

Level of Difficulty: 3 Hard Est Time: 3-5 minutes CASE STUDY #13: WARREN ELLIS Answer: 07BJ3ZX Feedback: 07BJ3ZX Alphabetic Index>excision>lymphatic>inguinal>left Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes CASE STUDY #14: HILLARY ROMINEY Answer: B246ZZZ Feedback: B246ZZZ - Alphabetic Index>ultrasonography>heart>bilateral Learning Objective: 39.01 Topic: Inpatient Coding Capstone Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes CASE STUDY #15: ELENA BEVERLY Answer: GZ52ZZZ, GZHZZZZ, GZ72ZZZ, GZ3ZZZZ Feedback: GZ52ZZZ - Alphabetic Index> psychotherapy>individual>mental health services> cognitive GZHZZZZ - Alphabetic Index>psychotherapy>group GZ72ZZZ - Alphabetic Index>psychotherapy>family Mental Health services GZ3ZZZZ - Alphabetic Index>Medication Management Learning Objective: 39.01 Topic: Inpatient Coding Capstone

Blooms: Apply CAAHEP: IX.C.2 CAAHEP: IX.P.2 ABHES: 7.d CAHIIM: I.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 40 Reimbursement 2024 Compliant Learning Outcomes

LO 40.1 Define the role of health insurance and managed care plans in the delivery of health care services. LO 40.2 Identify and define the types of health insurance plans. LO 40.3 Explain the types of compensation used in health care reimbursement. LO 40.4 Describe the information available for proper coding from NCCI edits and NCD and LCD. LO 40.5 Utilize Place-of-Service and Type-of-Service codes as required. LO 40.6 Create a system for organizing claims, understanding denials, and filing appeals.

Chapter Outline Learning Outcomes Key Terms The Role of Insurance in Health Care Types of Insurance Plans Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Point-of-Service (POS) Plan Federal Government Plans Centers for Medicare and Medicaid Services (CMS) TriCare Other Insurance Plans Methods of Compensation Fee-for-Service (FFS) Plans Capitation Plans Episodic Care Patient/Beneficiary Out-of-Pocket Contributions MACRA NCCI Edits and NCD/LCD National Correct Coding Initiative (NCCI) National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) Place-of-Service and Type-of-Service Codes Place-of-Service Codes Type-of -Service Codes Organizing Claims: Resubmission, Denials, and Appeals Chapter Summary Chapter 40 Review Let’s Check It! Terminology

Let’s Check It! Concepts Let’s Check It! Which Type of Insurance? Let’s Check It! Rules and Regulations Chapter Overview A professional coding specialist’s responsibility may not stop when the last code is determined. Remember, the codes you determine are used on requests for payment, known as reimbursement claims. Whenever money is involved, there are always legal and ethical issues attached, and you must familiarize yourself with all of the aspects for doing a complete and professional job for your facility, whether it is a small physician’s office or a huge hospital. Understanding these components ensures that you will have a career draped in honesty, integrity, and success. Discussion Activities 1. Explain, in your own words, the different types of compensation that can be used to reimburse a physician or health care facility for caring for a patient. (Learning Outcome: 40.3) 2. Explain, in your own words how you would use NCD and/or LCD information in the billing and reimbursement process. (Learning Outcome: 40.4) Additional Resources AAPC: www.aapc.com American Health Information Management Association: www.ahima.org American Medical Association: www.ama-assn.org The Joint Commission: www.jointcommission.org

Chapter 40 Review Answer Key

Let’s Check It! Terminology Part I: Answer: 1. I Gatekeeper 2. N Managed Care 3. K Health Maintenance Organization 4. M Liability Insurance 5. J Health Care 6. G Episodic Care 7. C Centers for Medicare & Medicaid Services (CMS) 8. H Fee-for-Service (FFS) Plans 9. F Discounted FFS 10. L Insurance Premium 11. A Automobile Insurance 12. B Capitation Plans 13. E Disability Compensation 14. D Dependents Learning Objective: 40.01 Learning Objective: 40.02 Learning Objective: 40.03 Topic: The Role of Insurance in Health Care

Topic: Types of Insurance Plans Topic: Methods of Compensation Blooms: Remember CAAHEP: VIII.C.1.a ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part II: Answer: 1. I Tracer 2. K Usual, Customary, and Reasonable (UCR) 3. B Electronic Remittance Advice (ERA) 4. E Point-of-Service (POS) 5. H Third-Party Payer 6. D Explanation of Benefits (EOB) 7. F Preferred Provider Organization (PPO) 8. J TriCare 9. L Workers‘ Compensation 10. A Electronic Media Claim 11. C Eligibility Verification 12. G Remittance Advice (RA) Learning Objective: 40.01 Learning Objective: 40.02 Learning Objective: 40.03 Learning Objective: 40.06 Topic: The Role of Insurance in Health Care Topic: Types of Insurance Plans Topic: Methods of Compensation Topic: Organizing Claims: Resubmission, Denials, and Appeals Blooms: Remember CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Part III: Answer: 1. F Auto Insurance Policy 2. D PPO

3. A Co-Payment 4. C Fee-for-Service 5. E Medicaid 6. B DRG Feedback: 1. F Auto Insurance Policy Automobile insurance might become an issue for your office if you treat someone for an injury that was caused by the individual‘s involvement in an automobile accident. Full-coverage automobile policies usually include liability insurance that cover these expenses. 2. D PPO In a preferred provider organization (PPO), physicians, hospitals, and other health care providers join together and agree to offer services to members of a group (often called subscribers) at a lower cost or discount. These plans usually permit the individual subscriber (the patient) to choose the physician or specialist to see, with a discount for staying in the network by using a physician who is a member of the plan. If the individual chooses a physician who does not belong to the network, or is not participating with that PPO, the individual will pay a penalty or receive less of a discount in the cost of those services. This can give the individual more control over his or her health care. It can save time and money, as well. 3. A Co-Payment Co-payment (also known as the co-pay). The co-payment is usually a fixed amount of money that the individual will pay each time he or she goes to a health care provider. It may be $10, $15, $20, or more. Each policy is different. As a matter of fact, the co-pay on the same policy for the same patient may be different, depending on whether this is a visit to a family physician, a specialist, or the hospital. 4. C Fee-for-Service In fee-for-service (FFS) plans, the insurance company pays the health care provider for each individual service supplied to the patient, as reported by the procedure codes listed on the claim, according to an agreed upon price list (also known as a fee schedule). When the physician‘s office agrees to participate in the plan, it is also agreeing to provide services and accept the amount of money indicated on that schedule for each of those services. 5. E Medicaid Medicaid is a plan that pays, or reimburses, for medical assistance and health care services for people who are indigent (lowincome). This program is funded by the federal government in cooperation with, and administered by, each state government. This means that each state determines who is eligible and what services are covered. It is important to know that each state has its own requirements, in case you have a patient that has just moved to your state. Each state may even have a unique name or term for its program. For example, in California the program is called Medi-Cal. 6. B DRG DRG: An episodic-care payment system basing reimbursement to hospitals for inpatient services upon standards of care for specific diagnoses grouped by their similar usage of resources for procedures, services, and treatments.

Learning Objective: 40.02 Learning Objective: 40.03 Topic: Types of Insurance Plans Topic: Methods of Compensation Blooms: Remember CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1. Answer: A identification and treatment of illness and/or injury. Feedback: Medical care is the identification and treatment of illnesses and injuries—in other words, whatever a health care provider does to help you with a health problem or concern that you have. Learning Objective: 40.01 Topic: The Role of Insurance in Health Care Blooms: Remember CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 2. Answer: C Health Maintenance Organization. Feedback: In a health maintenance organization (HMO), members, also called enrollees, prepay for health care services. The members are encouraged to get preventive treatment to promote wellness (and keep medical costs down). In addition, each member has a primary care physician (PCP), also known as a gatekeeper. The PCP is responsible for monitoring the individual‘s well-being and making all decisions regarding care. It is the PCP who determines if a specialist is required for a certain evaluation or procedure. When this occurs, it is the PCP who is responsible for completing the patient referral form and getting approval from the HMO for the patient to visit the specialist. Generally, HMOs do not require a patient to satisfy a deductible before benefits begin. (See the section ―Individual Insurance Contributions‖ later in this chapter.) Learning Objective: 40.02

Topic: Types of Insurance Plans Blooms: Remember CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 3. Answer: B per member every month. Feedback: With capitation plans, the insurance company pays the physician a fixed amount of money for every individual covered by that plan (often called members or subscribers) being seen by that physician. Physicians get this amount of money every month, as long as they are listed as the physician of record (primary care physician (PCP)) for that individual. Whether the insured person goes to see that physician once, three times, or not at all during a particular month, the physician‘s office will be paid the same amount. Learning Objective: 40.03 Topic: Methods of Compensation CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 4. Answer: C those over the age of 65. Feedback: Medicare is a national health insurance program that pays, or reimburses, for health care services provided to those over the age of 65. In addition, this plan may cover individuals who are under the age of 65 and are permanently disabled (such as the blind), as well as those with end-stage renal disease (ESRD) who are suffering from permanent kidney failure and require either dialysis or a kidney transplant. Learning Objective: 40.02 Topic: Types of Insurance Plans Blooms: Understand CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4

ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 5. Answer: C PTP Feedback: CMS computers evaluate submitted claims to look for pairs of codes being reported that are known mutually exclusive procedures, also known as procedure-to-procedure (PTP) edits. Learning Objective: 40.04 Topic: NCCI Edits and NCD/LCD Blooms: Understand CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 6. Answer: B those serving in the uniformed services. Feedback: TriCare was created to provide health care benefits for the dependents of those serving in the uniformed services and retirees. ADSMs are those from any of the seven uniformed services, include the U.S. military (the Army, Navy, Air Force, Marine Corps, and Coast Guard), as well as those serving in the Public Health Service, National Guard and Reserve, and the National Oceanic and Atmospheric Administration (NOAA). Eligibility for TRICARE is determined by the services and information is maintained in the Defense Enrollment Eligibility Reporting System (DEERS). Learning Objective: 40.02 Topic: Types of Insurance Plans Blooms: Understand CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 7. Answer: D Emergency Room-Hospital Feedback:

 POS code 23- Emergency Room-Hospital  POS code 02 - Telehealth  POS code 13 - Assisted Living Facility  POS code 20 - Urgent Care Facility Learning Objective: 40.05 Topic: Place-of-Service and Type-of-Service Codes Blooms: Understand CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 8. Answer: B transaction, document Feedback: The HIPAA Health Care Payment and Remittance Advice is the electronic transmission of this payment, using HIPAA approved secure data sets. The transmission has two parts: the transaction and the document.

1. The document is a remittance advice (RA) or an electronic remittance advice (ERA). Some health care professionals also refer to this document as an explanation of benefits or EOB. However, an EOB is sent to the patient or beneficiary, not the provider. 2. The transaction is an electronic fund transfer (EFT) that sends the payment directly into your facility‘s bank account, like direct deposit. Learning Objective: 40.06 Topic: Organizing Claims: Resubmission, Denials, and Appeals Blooms: Understand CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 9. Answer: C co-insurance. Feedback: Co-insurance. Co-insurance is different from the co-payment because it is based on a percentage of the total charge rather than a fixed amount. The percentage that the patient pays is most often calculated on the usual, customary, and reasonable (UCR) charge that has been determined for this type of visit or procedure. Frequently, the individual is required to pay

20% of the total allowed amount by the physician or facility, but that might differ for various types of policies and carriers. Learning Objective: 40.03 Topic: Methods of Compensation Blooms: Understand CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: C Centers for Medicare & Medicaid Services. Feedback: In 1977, the Health Care Financing Administration (HCFA, pronounced hic-fah) was created to coordinate federal health services programs. On July 1, 2001, HCFA became the Centers for Medicare & Medicaid Services (CMS). Many health care professionals still refer to this agency as ―HicFah‖ and to the CMS-1500 claim form as the ―HicFah 1500.‖ Old habits take a while to change. At least you now understand that these two acronyms refer to the same federal organization. Learning Objective: 40.02 Topic: Types of Insurance Plans Blooms: Remember CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Which Type of Insurance? Answer: 1. Workers‘ Compensation 2. Disability Compensation 3. Health Insurance 4. Automobile Insurance 5. Liability Insurance 6. Medicare 7. TriCare 8. Medicaid Feedback:

1. Mrs. Matthews, a teacher at Medical Coder Academy, slipped in her office, fell, and hurt her back. The correct answer is Workers’ Compensation 2. Ralph broke his leg and must be in traction for 9 months. What plan will help him pay his rent and electric bill? The correct answer is Disability Compensation 3. Keith was walking down the stairs in his house, fell over his son's toy, and twisted his ankle. The correct answer is Health Insurance 4. Marlene was driving to work when another car hit her from behind. The EMTs took her to the hospital with a sprained ankle and sore neck. The correct answer is Automobile Insurance 5. Jared enrolled in the insurance coding program at the local college. While leaving after his first class, another student bumped into him, he banged his head on a shelf, and he got a scalp laceration. The correct answer is Liability Insurance 6. At home after his 85th birthday party, Jack tripped on the rug, fell, and broke his hip. The correct answer is Medicare 7. Suzette's husband is in the Marines. She is pregnant with their first child. The correct answer is TriCare 8. James is out of work and has no prospects. He is broke and has a really bad sore throat. The correct answer is Medicaid Learning Objective: 40.01 Learning Objective: 40.02 Topic: The Role of Insurance in Health Care Topic: Types of Insurance Plans Blooms: Understand CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute

Let’s Check It! Rules and Regulations: 1. Answer: The CMS developed the National Correct Coding Initiative (NCCI) to reinforce accurate and proper coding in addition to preventing reimbursement of inaccurate amounts as the result of non-compliance coding methods in Part B claims (physician and outpatient services). This system is founded with coding policies based on the official coding guidelines, as published in American

Medical Association's CPT code book, as well as national (NCD) and local (LCD) policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. There are two types of edits within the NCCI focus: PTP and MUE. Feedback: The CMS developed the National Correct Coding Initiative (NCCI) to reinforce accurate and proper coding in addition to preventing reimbursement of inaccurate amounts as the result of non-compliance coding methods in Part B claims (physician and outpatient services). This system is founded with coding policies based on the official coding guidelines, as published in American Medical Association's CPT code book, as well as national (NCD) and local (LCD) policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. There are two types of edits within the NCCI focus: PTP and MUE. Learning Objective: 40.04 Topic: NCCI Edits and NCD/LCD Blooms: Understand CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: Within the long lists of procedures, services, and treatments performed by health care providers, there are those that cannot, or should not, be provided to the same patient on the same date of service. CMS computers evaluate submitted claims to look for pairs of codes being reported that are known mutually exclusive procedures, also known as procedure-to-procedure (PTP) edits. Feedback: Within the long lists of procedures, services, and treatments performed by health care providers, there are those that cannot, or should not, be provided to the same patient on the same date of service. CMS computers evaluate submitted claims to look for pairs of codes being reported that are known mutually exclusive procedures, also known as procedure-to-procedure (PTP) edits. Learning Objective: 40.04 Topic: NCCI Edits and NCD/LCD Blooms: Understand CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c

CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 3. Answer: The purpose of the NCCI medically unlikely edits (MUE) are to prevent improper payments when services are reported with incorrect units of service. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Feedback: The purpose of the NCCI medically unlikely edits (MUE) are to prevent improper payments when services are reported with incorrect units of service. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Learning Objective: 40.04 Topic: NCCI Edits and NCD/LCD Blooms: Understand CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 4. Answer: If you discover that the claim has been denied by the insurance carrier due to an error made by you or someone in your office, this can be fixed. Simply find out what the error was and correct it.

Compare the policy number on the claim to the copy of the insurance card that you made when the patient was seen in your office for this encounter. It is important that you specifically check it against the copy taken at the encounter for which this claim form is billing the insurance company. The patient may have been in your office more recently with a new policy because his or her insurance changed between the most recent visit and the visit for which this claim was submitted. You might find that, when you keyed the number into the computer, you inadvertently switched two numbers. It can happen when you are in a busy, hectic, noisy office with many people talking to you at the same time. If you find that the policy number matches the ID card, you will have to continue looking for the typo, going over the claim form one box at a time to check every piece of information that was entered. Once you find the error, all you have to do is correct it and resubmit a corrected claim form.

You should have caught the error when you double-checked your work, but . . . OK. It happens. You have wasted time (and if you are using a clearinghouse, you have wasted money as well), and you have delayed payment to your office, but follow the third-party payer‘s procedure for resubmitting corrected claims and the money will arrive. Feedback: If you discover that the claim has been denied by the insurance carrier due to an error made by you or someone in your office, this can be fixed. Simply find out what the error was and correct it. Compare the policy number on the claim to the copy of the insurance card that you made when the patient was seen in your office for this encounter. It is important that you specifically check it against the copy taken at the encounter for which this claim form is billing the insurance company. The patient may have been in your office more recently with a new policy because his or her insurance changed between the most recent visit and the visit for which this claim was submitted. You might find that, when you keyed the number into the computer, you inadvertently switched two numbers. It can happen when you are in a busy, hectic, noisy office with many people talking to you at the same time. If you find that the policy number matches the ID card, you will have to continue looking for the typo, going over the claim form one box at a time to check every piece of information that was entered. Once you find the error, all you have to do is correct it and resubmit a corrected claim form. You should have caught the error when you double-checked your work, but . . . OK. It happens. You have wasted time (and if you are using a clearinghouse, you have wasted money as well), and you have delayed payment to your office, but follow the third-party payer‘s procedure for resubmitting corrected claims and the money will arrive. Learning Objective: 40.06 Topic: Organizing Claims: Resubmission, Denials, and Appeals Blooms: Analyze CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: Should your office receive a denial based on lack of medical necessity, there are some things you must do: 1. Go back and confirm the diagnosis (ICD-10-CM) and procedure (CPT or ICD-10-PCS) codes that appear on the claim form are the best, most accurate codes. a. There is a possibility that there was a simple error in keying in the code (such as transposing two of the numbers or leaving off a digit). More than

once, a health care office and a patient have gone through months of arguing with the insurance carrier for the coverage of a procedure, only to find that the entire problem was a simple typographical error. b. Perhaps there was an error in coding. Go back and look at the physician‘s notes. Start from the beginning and recode the encounter. If there is another coder in your office, you might ask him or her to look at the notes and code the diagnosis and procedure(s). Then compare the other coder‘s determination of the best, most appropriate codes with yours. If you come up with different and/or additional codes this time, you might go ahead and resubmit the claim with the new codes. Or this review might confirm that the codes were correct on the original claim. c. Review the linking of the procedure codes to diagnosis codes (CMS-1500 Box 24E). Confirm the links are correct. 2. Contact the insurance carrier and get a written copy of its definition of medical necessity, or check its website and print it out. Often the list of criteria for medical necessity consists of any treatment or service that: a. Is commonly performed by health care practitioners (considered accepted standard of care) for the treatment of the condition, illness, or injury as indicated by the diagnosis code(s) provided b. Is provided at the most efficient level of care that ensures the patient‘s safety c. Is not experimental d. Is not elective Using the criteria for medical necessity from the insurance carrier that denied the claim (different carriers may have different criteria), review the patient‘s health record to confirm that this individual and this particular encounter meet all of the requirements. Again, o Double-check the diagnosis and procedure codes to make certain they all accurately represent what occurred during that visit. o Call and speak with the claims examiner to identify exactly what he or she thought the problem was with the claim. This conversation may give you some insight into what you should be looking for as you review the patient‘s chart. o Get support materials from your health care professionals, particularly the attending physician on this case. Copies of articles or pages from credible sources, such as The Merck Manual, the New England Journal of Medicine, or other qualified sources of research, will help support your claim. o If this patient encounter was the result of another provider referring the individual to your physician for additional treatment, the referring physician might agree to write a letter supporting your office. 3Write a letter to the third-party payer‘s appeals board, or to whomever the claims representative instructs you to send the documentation, outlining all of the information you have gathered to corroborate specifically why the denial should be overturned. a. Include copies of supporting documentation, such as pages from the National Library of Medicine's website or a letter from the referring provider.

b. In addition, request that a qualified health care professional licensed in the area of treatment or service under discussion be the one to review your appeal. This may provide a more agreeable opinion as to the medical necessity of your claim and get it approved. Feedback: Should your office receive a denial based on lack of medical necessity, there are some things you must do: 1. Go back and confirm the diagnosis (ICD-10-CM) and procedure (CPT or ICD-10-PCS) codes that appear on the claim form are the best, most accurate codes. a. There is a possibility that there was a simple error in keying in the code (such as transposing two of the numbers or leaving off a digit). More than once, a health care office and a patient have gone through months of arguing with the insurance carrier for the coverage of a procedure, only to find that the entire problem was a simple typographical error. b. Perhaps there was an error in coding. Go back and look at the physician‘s notes. Start from the beginning and recode the encounter. If there is another coder in your office, you might ask him or her to look at the notes and code the diagnosis and procedure(s). Then compare the other coder‘s determination of the best, most appropriate codes with yours. If you come up with different and/or additional codes this time, you might go ahead and resubmit the claim with the new codes. Or this review might confirm that the codes were correct on the original claim. c. Review the linking of the procedure codes to diagnosis codes (CMS-1500 Box 24E). Confirm the links are correct. 2. Contact the insurance carrier and get a written copy of its definition of medical necessity, or check its website and print it out. Often the list of criteria for medical necessity consists of any treatment or service that: a. Is commonly performed by health care practitioners (considered accepted standard of care) for the treatment of the condition, illness, or injury as indicated by the diagnosis code(s) provided b. Is provided at the most efficient level of care that ensures the patient‘s safety c. Is not experimental d. Is not elective Using the criteria for medical necessity from the insurance carrier that denied the claim (different carriers may have different criteria), review the patient‘s health record to confirm that this individual and this particular encounter meet all of the requirements. Again, o Double-check the diagnosis and procedure codes to make certain they all accurately represent what occurred during that visit. o Call and speak with the claims examiner to identify exactly what he or she thought the problem was with the claim. This conversation may give you some insight into what you should be looking for as you review the patient‘s chart. o Get support materials from your health care professionals, particularly the attending physician on this case. Copies of articles or pages from credible

sources, such as The Merck Manual, the New England Journal of Medicine, or other qualified sources of research, will help support your claim. o If this patient encounter was the result of another provider referring the individual to your physician for additional treatment, the referring physician might agree to write a letter supporting your office. 3Write a letter to the third-party payer‘s appeals board, or to whomever the claims representative instructs you to send the documentation, outlining all of the information you have gathered to corroborate specifically why the denial should be overturned. a. Include copies of supporting documentation, such as pages from the National Library of Medicine's website or a letter from the referring provider. b. In addition, request that a qualified health care professional licensed in the area of treatment or service under discussion be the one to review your appeal. This may provide a more agreeable opinion as to the medical necessity of your claim and get it approved. Learning Objective: 40.06 Topic: Organizing Claims: Resubmission, Denials, and Appeals Blooms: Evaluate CAAHEP: VIII.C.1.a CAAHEP: VIII.C.1.b CAAHEP: VIII.C.1.c CAAHEP: VIII.P.4 ABHES: 7.d CAHIIM: IV.A.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Chapter 41 Introduction to Health Care Law and Ethics 2024 Compliant Learning Outcomes LO 41.1 Identify the sources for directives governing behavior. LO 41.2 Understand the rules for ethical and legal coding. LO 41.3 Apply the requirements of the False Claims Act. LO 41.4 Translate the components of the Health Insurance Portability and Accountability Act’s Privacy Rule. LO 41.5 Elaborate the responsibilities of the Health Care Fraud and Abuse Control Program. LO 41.6 Adhere to the codes of ethics of our industry. LO 41.7 Analyze the reasons for creating a compliance plan.

Chapter Outline Learning Outcomes Key Terms

Sources for Legal Guidance The Federal Register Sources of Directives Rules for Ethical and Legal Coding Office of the Inspector General (OIG) Workplan False Claims Act Who Is Liable? What Is a Claim? The Knowledge Requirement The Qui Tam Provision Health Insurance Portability and Accountability Act (HIPAA) HIPAA’s Privacy Rule Who Is Responsible for Obeying This Law What This Law Covers Getting Written Approval Permitted Used and Disclosures Violating HIPAA’s Privacy Rule Health Care Fraud and Abuse Control Program Codes of Ethics American Health Information Management Association Code of Ethics AHIMA Standards of Ethical Coding AAPC Code of Ethical Standards Compliance Programs Chapter Summary Chapter 41 Review Let’s Check It! Terminology Let’s Check It! Concepts Let’s Check It! Rules and Regulations You Code It! Application Chapter Overview

As health care professionals, you will have special legal and ethical responsibilities that others, working in a standard business office, do not have. You will have the privilege to work with other health care professionals to help their patients and clients. In order to do this properly, you will have to have access to very personal and private information about that individual. In addition, as an insurance coding specialist, you will be working with data that also directly relates to how much your facility will be paid for its services; this is called reimbursement. As you can imagine, working with these two categories of information: personal information about an individual’s health; and how much professionals are being paid for their services, involve confidentiality, honesty, and accuracy. Try to encourage them to look at the healthcare environment from the perspective of a medical professional. How would their concept of the situation change given the new perspective? Legal and ethical issues can be very complicated. Some working professionals are misinformed. Others have not had the opportunity to learn the proper way to handle certain situations. This chapter is written to help you establish a firm foundation for your future career. Discussion Activities HIPAA [LEARNING OUTCOME: 41.4] 1. 2.

Think about the experiences in a healthcare facility you may have had or read about, or those of someone you know. Relate to your classmates, an experience relating to HIPAA, either the upholding of the terms of the Privacy

Rule, or in violation of the Privacy Rule. Include new perspective on this situation now that you understand HIPAA. If it was a negative experience, what would you do differently? I have had students relate experiences of picking up x-rays or medical records for relatives without being asked to show identification. Also, some students may relate stories of circumstances where they were prevented from getting information because staff were complying with the law. This is a great opportunity to help them get better perspective: what if they were not who they claimed to be; an old boyfriend/girlfriend or a co-worker trying to get the individual fired using health information, etc. Protection benefits everyone. You might ask them if there was ever a time when the student had a health issue or concern that he or she did not want even one person in the world to know. 3.

ETHICS & LEGALITIES [LEARNING OUTCOMES: 41.2 AND 41.6] PICK ONE OF THESE SCENARIOS AND EXPLAIN WHAT YOU WOULD DO IF YOU WERE TO ENCOUNTER THIS SITUATION ON THE JOB. 1.

The patient's chart notes that Dr. Johnson gave the five-year-old girl her MMR vaccine. Your office manager tells you to code each of the sera separately: using a different code for the Measles, the Mumps, and the Rubella instead of the one combination code because the office will get more money. She tells you that it can't be fraud because it is the truth; the doctor did give her all three vaccines. One analogy that most students can relate to involves the comparison of going to a fast food restaurant and purchasing the combo meal that is always offered for less money than the purchase of the burger, fries, and drink separately. Would your students want to pay the higher price? Why should the insurance company pay more? In addition, point out that the combination vaccine uses fewer resources with only one alcohol swab, one syringe, and one action by the nurse. Why should three times the resources be paid for when the extra material was not used? 2. You open a chart to code it for reimbursement. On the face sheet or the Superbill, you notice that Dr. Cipher has indicated that the procedure provided to the patient as: Flu Shot. However, you know for a fact that your office has no more flu vaccine and is not expecting a shipment until tomorrow. Not only is this illegal, it can create a very dangerous situation because the documentation states he or she is protected when in fact they are not. This can be life-threatening if the patient is in an at-risk population. Students should discuss what to do from the point of view that the physician made a human error (did this once or twice) as well as what to do when fraudulent behavior is identified (doing this time and time again). Actual Cases from the Office of the Inspector General (www.oig.hhs.gov) [Learning Outcomes: 41.1, 41.2, 41.3, 41.4, 41.5, 41.6, and 41.7]

1. In Ohio, a former owner of a home health agency was sentenced to 97 months in prison and ordered to pay $2.7 million in restitution pursuant to her conviction for her scheme to defraud the Government. The investigation revealed that from October 2001 through May 2003, Medicaid was billed for skilled nursing services that were not rendered as claimed. The woman billed for 14 hours of services per week when actually only 1 hour or less of services was provided per week. During the trial, it was also revealed that the woman instructed employees to falsify nursing notes. 2. In Washington D.C., a doctor was sentenced to 5 months incarceration and ordered to pay $155,000 in restitution for health care fraud. From October 2001 through March 2003, the doctor submitted claims to Medicare for Reteplase injections that were not given. Reteplase is a drug generally given in a hospital emergency room within the first three hours of a patient experiencing myocardial infarction (commonly referred to as a “heart attack”). The doctor submitted claims for one patient who purportedly had been injected 119 times. 3. In Illinois, a licensed speech-language pathologist was sentenced to 6 months home detention and ordered to pay $60,000 in restitution for health care fraud. From January 2001 to September 2002, the speech-language pathologist billed the Medicaid program

for services that were not provided. The investigation revealed that the woman altered or caused to be altered records to reflect therapy services that were not provided. 4. In Tennessee, the owner of a Texas durable medical equipment supplier was sentenced to 18 months in prison and ordered to pay $432,000 in restitution for violating the antikickback statute. Investigation revealed that the owner paid kickbacks of $1,000 for each certificate of medical necessity (CMN) she received. The CMNs were then used to bill Medicare for motorized wheelchairs for patients who had no need for the wheelchair. Patients either received no wheelchair at all or were provided with a less expensive scooter. 5. In Michigan, an attorney specializing in health care law was sentenced to 13 months incarceration and ordered to pay $98,000 in restitution for mail fraud. The attorney was hired by a physician group to negotiate a contractual joint venture agreement with a physical therapy company. As part of the negotiations, he was tasked with obtaining an official advisory opinion from OIG to ensure that the arrangement would not violate the anti-kickback statute. However, he did not request and obtain an advisory opinion from OIG but instead prepared false documents on copied OIG letterhead which falsely stated the joint venture met with the approval of OIG. 6. In Virginia, a personal care aide, who devised a scheme to defraud the Medicaid program, was sentenced to 5 months in jail and ordered to pay $58,000 in joint and several restitutions. Three co-defendants were previously sentenced for their involvement in the fraud scheme and held jointly liable for the restitution amount. The personal care aides caused the Medicaid program to pay for services not rendered by falsifying time sheets and personal care aide logs. ACTUAL CASES FROM THE INTERNAL REVENUE SERVICE (WWW.IRS.GOV) [Learning Outcome: 41.5] 1. On March 8, 2007, in Tyler, TX, Artis Anderson was sentenced to 24 months in federal prison and ordered to pay $828,092 in restitution for federal health care fraud violations and engaging in monetary transactions with property derived from specified unlawful activity. Anderson pleaded guilty to the charges on December 8, 2005. According to information presented in court, Anderson helped durable medical equipment providers in Houston, TX to submit fraudulent Medicare claims for motorized wheelchair and scooter reimbursement. He later opened a medical equipment business in Gregg County, TX and submitted fraudulent claims for motorized wheelchairs to Medicare. Additional Resources Health Care Fraud and Abuse Control Program: www.gao.gov Qui Tam Lawsuits (The Whistleblower Statute): www.dhhs.gov The Joint Commission: www.jointcommission.org

Office of Civil Rights (HIPAA): www.hhs.gov/ocr/hipaa Medicaid Fraud Control Unit: http://oig.hhs.gov/publications/mfcu.html National Correct Coding Initiative: www.cms.hhs.gov/NationalCorrectCodInitEd/ Federal Register: www.gpoaccess.gov/fr/index.html Health Care Law: H.R.3590—Patient Protection and Affordable Care Act (March 23, 2010): http://www.opencongress.org/bill/111-h3590/show Health Care Law News: Understanding the New Healthcare Law: http://www.healthcare.gov/law/introduction/index.html

HIPAA Violation: 27 Suspended for Clooney File Peek: http://www.cnn.com/2007/SHOWBIZ/10/10/clooney.records/index.html

Chapter 41 Review Answer Key Let’s Check It! Terminology Answer: 1. B Coding for Coverage 2. E Criminal Law 3. M Unbundling 4. H Executive Orders 5. A Administrative Law 6. D Covered Entities 7. J Protected Health Information (PHI) 8. K Statutory Laws 9. N Upcoding 10. I HIPAA‘s Privacy Rule 11. O Use 12. F Disclosure 13. C Common Law 14. L Supporting Documentation 15. G Double Billing Learning Objective: 41.01 Learning Objective: 41.02 Learning Objective: 41.04 Topic: Sources for Legal Guidance Topic: Rules for Ethical and Legal Coding Topic: Health Insurance Portability and Accountability Act Blooms: Remember CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute Let’s Check It! Concepts: 1.

Answer: D protect an individual‘s privacy and not interfere with the flow of information necessary for care. HIPAA‘s Privacy Rule is a portion of HIPAA that ensures the availability of patient information for those who should see it while protecting that information from those who should not. Learning Objective: 41.04 Topic: Health Insurance Portability and Accountability Act Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 2. Answer: A any health information that can be connected to a specific individual. Feedback: Protected health information (PHI) is any patient-identifiable health information regardless of the form in which it is stored (paper, computer file, etc.). In other words, it is information that anyone could look at and know exactly which individual is being discussed—one specific person like a social security number. Learning Objective: 41.04 Topic: Health Insurance Portability and Accountability Act Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 3. Answer: C health care computer software manufacturers. Feedback:

Covered entities are divided into three categories: • Health care providers • Health plans • Health care clearinghouses Learning Objective: 41.04 Topic: Health Insurance Portability and Accountability Act Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 4. Answer: C in the same office. Feedback: Use is the sharing of information between people working in the same health care facility for purposes of caring for the patient. Learning Objective: 41.04 Topic: Health Insurance Portability and Accountability Act Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 5. Answer: A and health care personnel in other covered entities. Feedback: Disclosure is the sharing of information between health care professionals working in separate entities, or facilities, in the course of caring for the patient. Learning Objective: 41.04 Topic: Health Insurance Portability and Accountability Act Blooms: Understand CAAHEP: X.C.3

CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 6. Answer: D Computer technical support Feedback: Covered entities are divided into three categories: • Health care providers • Health plans • Health care clearinghouses HIPAA‘s Privacy Rule went into effect on April 14, 2003, and concerns every physician‘s office, clinic, hospital, and health insurance carrier—every type of business that is directly involved in the delivery of and/or payment for health care services, no matter how big or small. Learning Objective: 41.04 Topic: Health Insurance Portability and Accountability Act Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 7. Answer: C AHIMA and AAPC. Feedback: There are two premier trade organizations for professional coding specialists: American Health Information Management Association and the American Academy of American Professional Coders. Each has published a code of ethics to guide members of our industry on the best professional way to conduct themselves. Learning Objective: 41.06 Topic: Codes of Ethics Blooms: Remember CAAHEP: X.C.3

CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 8. Answer: C volunteers, trainees, and employees, part time and full time. Feedback: A covered entity is responsible for any violation of HIPAA requirements by any of its employees, business associates, or any other members of its workforce, such as interns and volunteers. Generally, the senior officials of the covered entity may be punished for the lack of compliance; however, middle managers and staff members are not exempt.

Learning Objective: 41.04 Topic: Health Insurance Portability and Accountability Act Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 9. Answer: D all of these. Feedback: HIPAA‘s Privacy Rule was written to protect an individual‘s privacy with regard to personal health information, without getting in the way of the flow of data that is necessary to provide appropriate care for that patient. Essentially, the lawmakers tried to make certain that a patient‘s information is easily accessible to those who should have access to it (such as the physician, insurance coder and biller, and therapist) and, at the same time, keep it secured against unauthorized people (such as potential employers, coworkers, or neighborhood gossips) so that they do not see things they have no business seeing. Learning Objective: 41.04 Topic: Health Insurance Portability and Accountability Act Blooms: Understand CAAHEP: X.C.3

CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 10. Answer: C legal terminology so it will stand up in court. Feedback: In most situations the health care provider must get a patient‘s written permission to disclose the PHI. Although there are many preprinted forms that your office or facility may purchase, the Privacy Rule of HIPAA insists that all these documents have the following characteristics: • Are written in plain language (not legalese), so that the average person can understand what he or she is signing. • Are very specific as to exactly what information will be disclosed or used. • Specifically identify the person or organization that will be disclosing the information. • Specifically identify the person(s) who will be receiving the information. • Have a definite expiration date • Clearly explain that the person signing this release may retract this authorization in writing at any time Learning Objective: 41.04 Topic: Health Insurance Portability and Accountability Act Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 11. Answer: B any individual. Feedback: Any individual who discovers that his or her privacy has been misused or disclosed without permission can file a complaint with the

Department of Health and Human Services (DHHS) that the health care provider, health plan, or clearinghouse has not followed HIPAA‘s regulations. Learning Objective: 41.04 Topic: Health Insurance Portability and Accountability Act Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 12. Answer: C all covered entities. Feedback: All covered entities are responsible for any violation of HIPAA requirements by any of its employees, business associates, or any other members of its workforce, such as interns and volunteers. Generally, the senior officials of the covered entity may be punished for the lack of compliance; however, middle managers and staff members are not exempt. Learning Objective: 41.04 Topic: Health Insurance Portability and Accountability Act Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 13. Answer: C both federal and state law. Feedback: The False Claims Act (FCA), passed by Congress for Federal coverage, has been updated several times since 1986. In addition, virtually every state has passed its own version, enabling multiple jurisdictions to file multiple charges. What this means is that an individual may be charged with violation of the Federal law AND a violation of the state law. This law clearly

states who is liable and what the penalties are for failure to comply. The Department of Justice takes this enforcement seriously. Learning Objective: 41.03 Topic: False Claims Act Learning Objective: 41.04 Topic: Health Insurance Portability and Accountability Act Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 14. Answer: C Department of Health and Human Services. Feedback: DHHS stands for the Department of Health and Human Services. Learning Objective: 41.01 Topic: Sources for Legal Guidance Blooms: Remember CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 15. Answer: A coding for coverage. Feedback: Code for coverage is to choose a code by the insurance company‘s rules of what it will pay for, rather than a code that accurately reflects the truth about the encounter. Learning Objective: 41.02 Topic: Rules for Ethical and Legal Coding Learning Objective: 41.01 Topic: Sources for Legal Guidance Blooms: Remember

CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 16. Answer: C bill using several individual codes instead of one combination code. Feedback: Unbundling is coding individual parts of a specific procedure rather than one combination, or bundle that includes all the components. Learning Objective: 41.02 Topic: Rules for Ethical and Legal Coding Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 17. Answer: D bill using a code for a higher level of service than what was actually provided. Feedback: Upcoding is using a code on a claim form that indicates a higher level of service than that which was actually performed. Learning Objective: 41.02 Topic: Rules for Ethical and Legal Coding Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1

CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 18. Answer: D all of these. Feedback: The CCI is used to find coding conflicts, such as unbundling, the use of mutually exclusive codes, and other unacceptable reporting of CPT codes. When these errors are discovered, those claims are pulled for review and may be subject to possible suspension or rejection. Learning Objective: 41.02 Topic: Rules for Ethical and Legal Coding Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute 19. Answer: C $2.3 Feedback: By catching those who submitted fraudulent claims, approximately $2.3 billion was won or negotiated by the Federal government during fiscal year 2014. Learning Objective: 41.05 Topic: Health Care Fraud and Abuse Control Program Blooms: Remember CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 1 Easy Est Time: 0-1 minute 20. Answer: D cease disciplinary sanctions.

Feedback: The federal sentencing guidelines manual provides a seven-step list of the components of an effective compliance program. Federal Sentencing Guidelines Manual: The Seven Steps to Due Diligence 1. Establish compliance standards and procedures 2. Assign overall responsibility to specific high-level individual(s) 3. Use due care to avoid delegation of authority to individuals with an inclination to get involved in illegal actions 4. Effectively communicate standards and procedures to all staff 5. Utilize monitoring and auditing system to detect non-compliant conduct 6. Enforce adequate disciplinary sanctions when appropriate 7. Respond to episodes of non-compliance by modifying program, if necessary Learning Objective: 41.07 Topic: Compliance Programs Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 0-1 minute Let’s Check It! Rules and Regulations: 1. Answer: HIPAA‘s Privacy Rule was written to protect an individual‘s privacy with regard to personal health information, without getting in the way of the flow of data that is necessary to provide appropriate care for that patient. Essentially, the lawmakers tried to make certain that a patient’s information is easily accessible to those who should have access to it (such as the physician, insurance coder and biller, and therapist) and, at the same time, keep it secured against unauthorized people (such as potential employers, coworkers, or neighborhood gossips) so that they do not see things they have no business seeing. Feedback: HIPAA‘s Privacy Rule was written to protect an individual‘s privacy with regard to personal health information, without getting in the way of the flow of data that is necessary to provide appropriate care for that patient. Essentially, the lawmakers tried to make certain that a patient’s information is easily accessible to those who should have access to it (such as the physician, insurance coder and biller, and therapist) and, at the same time, keep it

secured against unauthorized people (such as potential employers, coworkers, or neighborhood gossips) so that they do not see things they have no business seeing. Learning Objective: 41.04 Topic: Health Insurance Portability and Accountability Act Blooms: Understand CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 2 Medium Est Time: 3-5 minutes 2. Answer: Double billing is sending a claim for the second time to the same insurance company for the same procedure or service, provided to the same patient on the same date of service. Double billing is not permissible. You must code all conditions or complications that are relevant to the current encounter. Separating the codes relating to one specific encounter and placing them on several different claim forms over the course of several different days is neither legal nor ethical. It not only indicates a lack of organization of the office but also can cause suspicion of duplicating service claims, known as double billing. Even if you are reporting procedures that were actually done for diagnoses that actually exist, remember that the claim form is a legal document. All data on that claim form, including dates of service, must be accurate. Do not submit the claim form until you are certain it is complete, with all diagnoses and procedures listed. If it happens that, after you submit a claim, an additional service provided comes to light (such as a lab report with an extra charge that didn't come across your desk until after you filed the claim), then you must file an amended claim. While not illegal because you are identifying that the claim contains an adjustment, most third-party payers really dislike amended claims. You can expect an amended claim to be scrutinized. Feedback: Double billing is sending a claim for the second time to the same insurance company for the same procedure or service, provided to the same patient on the same date of service. Double billing is not permissible. You must code all conditions or complications that are relevant to the current encounter. Separating the codes relating to one specific encounter and placing them on several different claim forms over the course of several different days is neither legal nor ethical. It not only indicates a lack of organization of the office but also can cause suspicion of duplicating service claims, known as double billing. Even if you are reporting procedures that were actually done for

diagnoses that actually exist, remember that the claim form is a legal document. All data on that claim form, including dates of service, must be accurate. Do not submit the claim form until you are certain it is complete, with all diagnoses and procedures listed. If it happens that, after you submit a claim, an additional service provided comes to light (such as a lab report with an extra charge that didn't come across your desk until after you filed the claim), then you must file an amended claim. While not illegal because you are identifying that the claim contains an adjustment, most third-party payers really dislike amended claims. You can expect an amended claim to be scrutinized. Learning Objective: 41.02 Topic: Rules for Ethical and Legal Coding Blooms: Apply CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 3. Answer: Civil law governs the conduct of those involved in a relationship: between private companies, individuals, and sometimes the government. Most often, a civil complaint or lawsuit will result from one party accusing the other of failure to comply with the terms of a contract. There are many instances of contractual relationships throughout the healthcare industry. Physicians and health care facilities may contract with a managed care organization; some facilities use contract workers to fill in for staff members on vacation; a family may contract with a home health care agency for services to a homebound patient; and the federal government may contract for health care services from a professional that does not include direct patient care. The violation of a patient‘s confidentiality falls into this category because, in the United States, privacy is considered a civil right. This is why an alleged violation of privacy laws is handled through the Office of Civil Rights (OCR) within the Department of Health and Human Services (DHHS) of the federal government. Feedback: Civil law governs the conduct of those involved in a relationship: between private companies, individuals, and sometimes the government. Most often, a civil complaint or lawsuit will result from one party accusing the other of failure to comply with the terms of a contract. There are many instances of contractual relationships throughout the healthcare industry. Physicians and health care facilities may contract with a managed care organization; some facilities use contract workers to fill in for staff members on vacation; a family

may contract with a home health care agency for services to a homebound patient; and the federal government may contract for health care services from a professional that does not include direct patient care. The violation of a patient‘s confidentiality falls into this category because, in the United States, privacy is considered a civil right. This is why an alleged violation of privacy laws is handled through the Office of Civil Rights (OCR) within the Department of Health and Human Services (DHHS) of the federal government. Learning Objective: 41.01 Topic: Sources for Legal Guidance Blooms: Apply CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 4. Answer: The False Claims Act‘s (FCA) specific definition of what a claim is, "a demand for money or property made directly to the Federal Government or to a contractor, grantee, or other recipient". Under the requirements of the individual state governments, this would be a demand for reimbursement from the state government or other entity within. In addition, this law includes a "Knowledge Requirement". This portion of the law states that the simple action of submitting a claim with false information is not a violation. The individual must know that the information on the claim is false. What does "know" mean? • Actual knowledge... knowing for a fact that the information is false • Willful ignorance, also known as deliberate ignorance ... those who should know, due to their job position, training, or responsibilities within the organization with regard to filing the claim, but purposely don't ask about the validity of the information, or ignore the falsity of the information • Disregard of the truth or falsity ... behavior that exhibits an indifference to confirming that the information is true Feedback: The False Claims Act‘s (FCA) specific definition of what a claim is, "a demand for money or property made directly to the Federal Government or to a contractor, grantee, or other recipient". Under the requirements of the individual state governments, this would be a demand for reimbursement from the state government or other entity within. In addition, this law includes a "Knowledge Requirement". This portion of the law states that the simple action of submitting a claim with false information is

not a violation. The individual must know that the information on the claim is false. What does "know" mean? • Actual knowledge... knowing for a fact that the information is false • Willful ignorance, also known as deliberate ignorance ... those who should know, due to their job position, training, or responsibilities within the organization with regard to filing the claim, but purposely don't ask about the validity of the information, or ignore the falsity of the information • Disregard of the truth or falsity ... behavior that exhibits an indifference to confirming that the information is true Learning Objective: 41.03 Topic: False Claims Act Blooms: Apply CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes 5. Answer: The federal sentencing guidelines manual provides a seven-step list of the components of an effective compliance program. Federal Sentencing Guidelines Manual: The Seven Steps to Due Diligence 1. Establish compliance standards and procedures 2. Assign overall responsibility to specific high-level individual(s) 3. Use due care to avoid delegation of authority to individuals with an inclination to get involved in illegal actions 4. Effectively communicate standards and procedures to all staff 5. Utilize monitoring and auditing system to detect non-compliant conduct 6. Enforce adequate disciplinary sanctions when appropriate 7. Respond to episodes of non-compliance by modifying program, if necessary Feedback: The federal sentencing guidelines manual provides a seven-step list of the components of an effective compliance program. Federal Sentencing Guidelines Manual: The Seven Steps to Due Diligence 1. Establish compliance standards and procedures 2. Assign overall responsibility to specific high-level individual(s) 3. Use due care to avoid delegation of authority to individuals with an inclination to get involved in illegal actions

4. Effectively communicate standards and procedures to all staff 5. Utilize monitoring and auditing system to detect non-compliant conduct 6. Enforce adequate disciplinary sanctions when appropriate 7. Respond to episodes of non-compliance by modifying program, if necessary Learning Objective: 41.07 Topic: Compliance Programs Blooms: Apply CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes You Code It! Application Application 1: Felecia Holland Answer: Code the claim honestly and accurately. Consider the consequences of filing a false claim, including ethical and legal penalties. Also consider the future ramifications of the patient potentially being denied insurance in the future because she ―reportedly‖ had a procedure that may identify a future pre-existing condition. Feedback: Code the claim honestly and accurately. Consider the consequences of filing a false claim, including ethical and legal penalties. Also consider the future ramifications of the patient potentially being denied insurance in the future because she ―reportedly‖ had a procedure that may identify a future pre-existing condition. Learning Objective: 41.01 Learning Objective: 41.02 Learning Objective: 41.03 Learning Objective: 41.04 Learning Objective: 41.05 Learning Objective: 41.06 Learning Objective: 41.07 Topic: Sources for Legal Guidance Topic: Rules for Ethical and Legal Coding Topic: False Claims Act Topic: Health Insurance Portability and Accountability Act

Topic: Health Care Fraud and Abuse Control Program Topic: Codes of Ethics Topic: Compliance Programs Blooms: Apply CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 2: Marc Okonek Answer: Query the physician to see if he can provide the needed documentation without appearing to ‗question‘ the physician‘s authority or knowledge. Consider the legal and ethical issues involved with documentation~ ―If it‘s not documented, it didn‘t happen. If it didn‘t happen, you can‘t code it‖ Feedback: Query the physician to see if he can provide the needed documentation without appearing to ‗question‘ the physician‘s authority or knowledge. Consider the legal and ethical issues involved with documentation~ ―If it‘s not documented, it didn‘t happen. If it didn‘t happen, you can‘t code it‖ Learning Objective: 41.01 Learning Objective: 41.02 Learning Objective: 41.03 Learning Objective: 41.04 Learning Objective: 41.05 Learning Objective: 41.06 Learning Objective: 41.07 Topic: Sources for Legal Guidance Topic: Rules for Ethical and Legal Coding Topic: False Claims Act Topic: Health Insurance Portability and Accountability Act Topic: Health Care Fraud and Abuse Control Program Topic: Codes of Ethics Topic: Compliance Programs Blooms: Apply CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f

ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 3: Elizabeth Rials Answer: Do not provide the medical records without the proper authorization. Value privacy over the appearance of convenience~ ―trust but verify‖. First, there is no way to know that Felicia is really Joan‘s sister. Second, we have no way of knowing the true relationship between these two individuals even if they are sisters. Being a relative does not automatically mean the two people are close and loving. There could be custody issues, inheritance issues, etc. Feedback: Do not provide the medical records without the proper authorization. Value privacy over the appearance of convenience~ ―trust but verify‖. First, there is no way to know that Felicia is really Joan‘s sister. Second, we have no way of knowing the true relationship between these two individuals even if they are sisters. Being a relative does not automatically mean the two people are close and loving. There could be custody issues, inheritance issues, etc. Learning Objective: 41.01 Learning Objective: 41.02 Learning Objective: 41.03 Learning Objective: 41.04 Learning Objective: 41.05 Learning Objective: 41.06 Learning Objective: 41.07 Topic: Sources for Legal Guidance Topic: Rules for Ethical and Legal Coding Topic: False Claims Act Topic: Health Insurance Portability and Accountability Act Topic: Health Care Fraud and Abuse Control Program Topic: Codes of Ethics Topic: Compliance Programs Blooms: Apply CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1

Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 4: Sandra Singelton Answer: Do not give out PHI without written authorization on file. Remember that, as healthcare professionals, it is not our place to get involved in the relationships between a patient and anyone else: spouse, parent, child, sibling. The laws are there to provide support to us to protect our patient and their confidentiality. Feedback: Do not give out PHI without written authorization on file. Remember that, as healthcare professionals, it is not our place to get involved in the relationships between a patient and anyone else: spouse, parent, child, sibling. The laws are there to provide support to us to protect our patient and their confidentiality. Learning Objective: 41.01 Learning Objective: 41.02 Learning Objective: 41.03 Learning Objective: 41.04 Learning Objective: 41.05 Learning Objective: 41.06 Learning Objective: 41.07 Topic: Sources for Legal Guidance Topic: Rules for Ethical and Legal Coding Topic: False Claims Act Topic: Health Insurance Portability and Accountability Act Topic: Health Care Fraud and Abuse Control Program Topic: Codes of Ethics Topic: Compliance Programs Blooms: Apply CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes Application 5: Carl Everfield Answer: Code the claim honestly and accurately with the documentation provided in the chart. If the physician provides documentation showing medical necessity for a deviated septum then you can code it.

Feedback: Code the claim honestly and accurately with the documentation provided in the chart. If the physician provides documentation showing medical necessity for a deviated septum then you can code it. Learning Objective: 41.01 Learning Objective: 41.02 Learning Objective: 41.03 Learning Objective: 41.04 Learning Objective: 41.05 Learning Objective: 41.06 Learning Objective: 41.07 Topic: Sources for Legal Guidance Topic: Rules for Ethical and Legal Coding Topic: False Claims Act Topic: Health Insurance Portability and Accountability Act Topic: Health Care Fraud and Abuse Control Program Topic: Codes of Ethics Topic: Compliance Programs Blooms: Apply CAAHEP: X.C.3 CAAHEP: X.C.13 CAAHEP: X.P.2.a ABHES: 4.f ABHES: 4.h ABHES: 7.d CAHIIM: I.A.1 CAHIIM: II.A.1 CAHIIM: II.B.1 Level of Difficulty: 3 Hard Est Time: 3-5 minutes

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FOLLOWING DATA IS NOT RELATED TO THE ABOVE DOCUMENT [IGNORE THIS] EXTRA INFORMATION [PLEASE IGNORE THIS][BY ARHAD] 1. **Introduction toBiology**: thetextbook likely starts with an introduction tothescientific method, basic principles of biology, and an overview of theorganization of life from molecules toecosystems. 2. **Cell Structure and Function**: Detailed exploration of cell biology, covering topics such as cell structure, organelles, cell membrane dynamics, and cellular processes like metabolism and cell division. 3. **Genetics and Molecular Biology**: Coverage of genetics principles including Mendelian inheritance, molecular genetics, DNA structure, replication, transcription, translation, and gene regulation. 4. **Evolution and Natural Selection**: Explanation of evolutionary processes, evidence forevolution, mechanisms of evolutionary change (e.g., natural selection, genetic drift, gene flow), and patterns of biodiversity. 5. **Ecology**: Study of interactions between organisms and their environment, including ecological principles, ecosystems, community dynamics, population ecology, and conservation biology. 6. **Diversity of Life**: Examination of thediversity of organisms across kingdoms, including prokaryotes, protists, fungi, plants, and animals. This section may also cover taxonomy, phylogenetics, and evolutionary relationships. 7. **Plant Structure and Function**: Focus on plant biology, including plant anatomy, physiology, reproduction, and plant responses totheenvironment (e.g., tropisms, photosynthesis,

water and nutrient uptake). 8. **Animal Structure and Function**: Exploration of animal biology, covering animal diversity, anatomy, physiology, behavior, and adaptations tovarious environments. 9. **Human Biology**: Integration of human biology topics, including human anatomy, physiology, genetics, and health-related issues like disease prevention and nutrition. 10. **Ecological and Environmental Issues**: Discussion of current environmental challenges, human impact on ecosystems, sustainability, and conservation biology efforts.

11. **Scientific Inquiry and Skills**: Emphasis on critical thinking skills, scientific methods, experimental design, data analysis, and interpretation of scientific literature. 12. **Illustrations and Learning Aids**: thetextbook likely includes numerous illustrations, diagrams, tables, and summary boxes toaid in understanding key concepts and visualizing biological processes. The "Essentials of Biology" series by Sylvia Mader and Michael Windelspecht is known forits clear explanations, comprehensive coverage of foundational biological concepts, and relevance toboth majors and non-majors in biology. It is often used in introductory biology courses at theundergraduate level. If you have specific chapters or topics within thebook that you'd like more detailed information on, feel free toask!

Chapter 1: Chapter 1: Biology: theScience of Life In "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, Chapter 1 typically serves as an introduction tothefield of biology, laying thefoundation forunderstanding thescientific study of life. Here's an overview of what you might find in Chapter 1: 1. **Introduction toBiology**: - Definition of biology as thescientific study of life, including its scope and relevance tounderstanding living organisms and their interactions with theenvironment. 2. **Scientific Method**: - Explanation of thescientific method as thesystematic approach toinvestigating natural phenomena, including observation, hypothesis formation, experimentation, data collection, and conclusion drawing. 3. **Characteristics of Life**: - Discussion on thefundamental characteristics shared by all living organisms, such as cellular organization, metabolism, growth, adaptation, response tostimuli, reproduction, and evolution. 4. **Levels of Biological Organization**: - Exploration of biological hierarchy, from molecules and cells toorganisms, populations, communities, ecosystems, and thebiosphere. 5. **Emerging Themes in Biology**: - Identification of key themes and concepts that unify thestudy of biology, including evolution,

structure and function, information flow, energy transformations, and interactions within biological systems. 6. **Interdisciplinary Nature of Biology**:

- Recognition of biology as an interdisciplinary field that integrates principles and methods from chemistry, physics, mathematics, computer science, and other disciplines tounderstand complex biological phenomena. 7. **Ethical and Societal Implications**: - Consideration of ethical issues, societal implications, and applications of biological knowledge in areas such as medicine, biotechnology, conservation, and environmental sustainability. 8. **Historical Perspectives**: - Overview of significant milestones and contributions in thedevelopment of biology as a scientific discipline, including key figures, discoveries, and advancements in biological theories. 9. **Tools and Techniques**: - Introduction tolaboratory techniques, instruments, and methodologies used in biological research, such as microscopy, DNA sequencing, biochemical analysis, and computational biology. 10. **Current Challenges and Frontiers**: - Discussion on contemporary challenges facing biology, such as emerging infectious diseases, climate change impacts, biodiversity loss, and theapplication of biotechnological innovations. 11. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts discussed, reinforcing thefoundational principles of biology and preparing students forfurther exploration in subsequent chapters. Chapter 1 of "Essentials of Biology" aims toprovide students with a comprehensive introduction tothescientific study of life, emphasizing its breadth, significance, and relevance in understanding thenatural world and addressing global challenges. It sets thestage fordeeper exploration into biological concepts and principles covered throughout thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 1, feel free toask!

CHAPTER 2 Chapter 2 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "The Chemical Basis of Life," typically delves into thefoundational principles of chemistry as they relate tobiological systems. Here’s an overview of what you might find in this chapter:

1. **Introduction toBiochemistry**: - Definition of biochemistry as thebranch of chemistry concerned with thechemical processes and substances that occur within living organisms.

2. **Elements and Atoms**: - Explanation of basic chemical elements essential tolife, their atomic structure (protons, neutrons, electrons), and how atoms combine toform molecules. 3. **Chemical Bonds**: - Discussion on different types of chemical bonds (covalent, ionic, hydrogen bonds) and their role in holding atoms together in molecules and compounds. 4. **Properties of Water**: - Exploration of water as a polar molecule, its unique properties (high cohesion, adhesion, surface tension, high specific heat capacity), and its importance in biological systems. 5. **Acids, Bases, and pH**: - Definition of acids and bases, their role in chemical reactions, and theconcept of pH as a measure of hydrogen ion concentration. Importance of pH regulation in biological processes. 6. **Organic Molecules**: - Introduction toorganic molecules essential forlife, including carbohydrates, lipids, proteins, and nucleic acids. Structure, function, and biological significance of each group of molecules. 7. **Carbohydrates**: - Structure of carbohydrates (monosaccharides, disaccharides, polysaccharides), their roles as energy sources and structural components in cells. 8. **Lipids**: - Classification of lipids (fats, phospholipids, steroids), their structure, functions (energy storage, cell membranes), and roles in biological processes. 9. **Proteins**: - Structure of proteins (amino acids, primary, secondary, tertiary, and quaternary structure), functions (enzymes, structural proteins, antibodies), and protein synthesis. 10. **Nucleic Acids**: - Structure and function of nucleic acids (DNA and RNA), including nucleotide structure, DNA replication, transcription, and translation. 11. **Enzymes and Catalysis**: - Role of enzymes as biological catalysts, enzyme-substrate interactions, enzyme specificity, factors influencing enzyme activity, and regulation of enzyme function. 12. **Energy and Metabolism**: - Overview of energy transformations in biological systems, including an introduction tometabolism, energy carriers (ATP), and metabolic pathways (e.g., glycolysis, Krebs cycle). 13. **Summary and Key Concepts**:

- The chapter concludes with a summary of key concepts related tothechemical basis of life, reinforcing understanding of thefoundational principles of biochemistry and their significance in biological processes. Chapter 2 provides a comprehensive introduction tothechemical foundations that underpin biological systems. It establishes a crucial understanding of how chemical principles govern thestructure, function, and interactions of biological molecules essential forlife. This knowledge serves as a basis forfurther exploration into cellular processes, genetics, and physiological mechanisms covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 2, feel free toask!

Chapter 3 Chapter 3 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "The Organic Molecules of Life," focuses specifically on themajor classes of organic molecules essential forbiological systems. Here’s an overview of what you might find in this chapter: 1. **Introduction toOrganic Molecules**: - Definition of organic molecules and their importance as thebuilding blocks of life. Overview of themajor classes of organic molecules: carbohydrates, lipids, proteins, and nucleic acids. 2. **Carbohydrates**: - Detailed exploration of carbohydrates, including: - **Monosaccharides**: Structure (e.g., glucose, fructose), function as energy sources, and roles in cellular processes. - **Disaccharides**: Formation from monosaccharides (e.g., sucrose, lactose) and biological significance. - **Polysaccharides**: Structure (e.g., starch, glycogen, cellulose), function as energy storage (starch, glycogen) and structural support (cellulose). 3. **Lipids**: - Examination of lipids, including: - **Fats and Oils**: Structure (triglycerides), function as energy storage and insulation. - **Phospholipids**: Structure, role in cell membranes (phospholipid bilayer), and amphipathic nature. - **Steroids**: Structure (e.g., cholesterol), roles as hormones (e.g., estrogen, testosterone) and membrane components. 4. **Proteins**: - In-depth coverage of proteins, including: - **Amino Acids**: Structure of amino acids, classification (essential vs. non-essential), and

role as protein building blocks. - **Protein Structure**: Levels of protein structure (primary, secondary, tertiary, quaternary) and factors influencing protein folding.

- **Protein Functions**: Roles of proteins as enzymes (catalysts), structural components (e.g., collagen, keratin), antibodies, transport proteins, and hormones. 5. **Nucleic Acids**: - Exploration of nucleic acids, focusing on: - **DNA**: Structure (double helix), nucleotide components (adenine, thymine, cytosine, guanine), and function as genetic material, replication, and inheritance. - **RNA**: Types of RNA (messenger RNA, transfer RNA, ribosomal RNA), roles in protein synthesis (transcription, translation), and gene expression regulation. 6. **Chemical Diversity and Functionality**: - Discussion on thechemical diversity within each class of organic molecules and their diverse functions in cellular processes, metabolism, and maintaining homeostasis. 7. **Interactions and Biological Significance**: - Emphasis on interactions between different classes of organic molecules and their integration into complex biological systems tosupport life processes. 8. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related totheorganic molecules of life, reinforcing understanding of their structures, functions, and roles in biological processes. Chapter 3 provides a comprehensive overview of theorganic molecules essential forlife, laying thegroundwork forunderstanding their biochemical properties, biological functions, and contributions tocellular and organismal biology. It serves as a crucial foundation forfurther exploration into cellular structure and function, genetics, and physiological mechanisms covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 3, feel free toask! Chapter 4: Inside theCell Chapter 4 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Inside theCell," typically focuses on thestructure and functions of cells, which are thebasic units of life. Here’s an overview of what you might find in this chapter: 1. **Introduction toCells**: - Definition of cells as thefundamental units of life, their diversity in structure and function, and theCell Theory. 2. **Cell Structure**: - Exploration of thestructure of typical eukaryotic cells, including:

- **Cell Membrane**: Structure, composition (lipid bilayer, proteins), functions in cell transport, signaling, and recognition. - **Cytoplasm**: Composition, organelles suspended within (e.g., cytoskeleton, ribosomes). - **Nucleus**: Structure, functions (DNA storage, transcription, regulation of cell activities).

- **Organelles**: Detailed examination of organelles such as mitochondria, endoplasmic reticulum, Golgi apparatus, lysosomes, and their roles in cellular processes. 3. **Prokaryotic Cells**: - Comparison of prokaryotic and eukaryotic cell structures, emphasizing differences in organelles, genetic material (no nucleus in prokaryotes), and cellular processes. 4. **Cellular Organization and Function**: - Integration of cellular components and organelles tosupport cellular functions such as metabolism, protein synthesis, energy production (e.g., ATP synthesis), and maintenance of homeostasis. 5. **Cellular Transport**: - Mechanisms of cellular transport, including: - **Passive Transport**: Diffusion, osmosis, facilitated diffusion. - **Active Transport**: Ion pumps, carrier proteins, endocytosis, exocytosis. - **Bulk Transport**: Phagocytosis, pinocytosis. 6. **Cell Communication**: - Overview of cellular communication processes, including: - **Receptor Proteins**: Recognition of signaling molecules (ligands). - **Signal Transduction**: Transmission of signals within cells (e.g., second messengers). - **Cell Signaling Pathways**: Examples of signaling pathways (e.g., hormone signaling, neurotransmission). 7. **Cell Cycle and Cell Division**: - Phases of thecell cycle (interphase, mitosis, cytokinesis) and their regulation. - Importance of cell division in growth, repair, and reproduction. 8. **Cancer and Cell Regulation**: - Introduction tocancer as uncontrolled cell growth and division. - Causes of cancer (mutations, environmental factors), mechanisms of tumor formation, and approaches tocancer treatment. 9. **Stem Cells and Regenerative Medicine**: - Overview of stem cells, their properties (pluripotent, multipotent), and potential applications in regenerative medicine and research. 10. **Microscopy and Cell Visualization**: - Techniques and types of microscopy used tostudy cells, including light microscopy, electron microscopy, and fluorescence microscopy. 11. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related tocell structure, function, and organization, reinforcing understanding of cellular biology fundamentals.

Chapter 4 provides a comprehensive exploration of thestructure and functions of cells, highlighting their complexity and organization at themicroscopic level. It serves as a foundational chapter in understanding how cellular structures and processes contribute tothefunctioning of organisms and ecosystems. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 4, feel free toask!

Chapter 5 Chapter 5 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "The Dynamic Cell," typically explores thedynamic processes and activities that occur within cells. Here’s an overview of what you might find in this chapter: 1. **Introduction toCellular Dynamics**: - Definition of cellular dynamics and an overview of thedynamic processes that occur within cells tomaintain life and respond toenvironmental changes. 2. **Energy Transformations**: - Exploration of cellular energy processes, including: - **Cellular Respiration**: Overview of aerobic and anaerobic respiration, including glycolysis, Krebs cycle, and oxidative phosphorylation (electron transport chain). - **Photosynthesis**: Overview of photosynthetic processes in plants and algae, including light reactions and Calvin cycle. 3. **Metabolic Pathways**: - Detailed examination of metabolic pathways within cells, including: - **Catabolic Pathways**: Breakdown of molecules (e.g., glucose) torelease energy. - **Anabolic Pathways**: Synthesis of molecules (e.g., proteins, lipids) using energy. 4. **Cellular Respiration**: - Explanation of theprocess of cellular respiration, focusing on theconversion of glucose and oxygen into ATP, carbon dioxide, and water. Includes discussion on therole of mitochondria in ATP production. 5. **Photosynthesis**: - Overview of photosynthesis as theprocess by which plants and other organisms convert light energy into chemical energy (glucose), releasing oxygen as a byproduct. Includes discussion on chloroplast structure and function. 6. **Cellular Transport**: - Further exploration of cellular transport mechanisms introduced in Chapter 4, including active transport, passive transport (diffusion, osmosis), and bulk transport (endocytosis, exocytosis).

7. **Cellular Movement and Cytoskeleton**:

- Role of thecytoskeleton (microtubules, actin filaments, intermediate filaments) in cellular structure, movement, and support. Includes discussion on cell motility and cell shape changes. 8. **Cellular Communication**: - Expanded discussion on cell signaling processes introduced in Chapter 4, including signal reception, transduction pathways, and cellular responses toenvironmental signals (e.g., hormones, neurotransmitters). 9. **Cellular Regulation and Homeostasis**: - Mechanisms by which cells maintain internal balance and respond tochanges in their environment. Includes discussion on feedback mechanisms, regulatory proteins, and cellular adaptation. 10. **Cellular Reproduction**: - Overview of cell division processes, including mitosis and meiosis, and their roles in growth, repair, and reproduction. Includes discussion on cell cycle checkpoints and regulatory mechanisms. 11. **Emerging Topics in Cellular Biology**: - Introduction tocurrent research topics and advancements in cellular biology, such as stem cell research, cellular reprogramming, and synthetic biology. 12. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related tocellular dynamics, reinforcing understanding of thedynamic processes that occur within cells and their importance in maintaining life. Chapter 5 provides a comprehensive exploration of thedynamic processes within cells, highlighting their complexity and interconnectedness. It builds upon thefoundational knowledge of cell structure (covered in Chapter 4) and prepares students forfurther exploration into genetics, cellular specialization, and physiological mechanisms covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 5, feel free toask! Chapter 6: Energy forLife Chapter 6 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Energy forLife," typically focuses on thefundamental principles of energy flow and metabolism within biological systems. Here’s an overview of what you might find in this chapter: 1. **Introduction toEnergy and Metabolism**: - Definition of metabolism as thesum of all chemical reactions occurring in an organism tomaintain life. Introduction toenergy transformations and their importance in cellular processes.

2. **Forms of Energy**:

- Exploration of different forms of energy relevant tobiological systems, including chemical energy (stored in bonds of molecules like ATP), kinetic energy, and potential energy. 3. **First and Second Laws of Thermodynamics**: - Explanation of thelaws of thermodynamics as they apply tobiological systems: - **First Law**: Conservation of energy. - **Second Law**: Increase in entropy (disorder) over time. - Application of these laws tounderstand energy flow and transformations in cells. 4. **Energy Currency of Cells: ATP**: - Detailed examination of ATP (adenosine triphosphate) as theprimary energy carrier molecule in cells. Structure, function (energy transfer), and regeneration of ATP through cellular respiration and photosynthesis. 5. **Cellular Respiration**: - In-depth coverage of cellular respiration as theprocess by which cells harvest energy from glucose and other organic molecules toproduce ATP. Includes: - **Glycolysis**: Breakdown of glucose into pyruvate, with net production of ATP and NADH. - **Krebs Cycle (Citric Acid Cycle)**: Further breakdown of pyruvate togenerate electron carriers (NADH, FADH2). - **Electron Transport Chain**: Final stage of aerobic respiration, where electron carriers donate electrons togenerate ATP via oxidative phosphorylation. 6. **Anaerobic Respiration and Fermentation**: - Overview of anaerobic pathways (e.g., fermentation) as alternative mechanisms forATP production in theabsence of oxygen. Comparison toaerobic respiration in terms of efficiency and end products. 7. **Photosynthesis**: - Recapitulation of photosynthesis as theprocess by which plants, algae, and some bacteria convert light energy into chemical energy (glucose) and oxygen. Includes: - **Light Reactions**: Conversion of light energy tochemical energy (ATP, NADPH). - **Calvin Cycle (Dark Reactions)**: Incorporation of carbon dioxide into organic molecules (sugar synthesis). 8. **Metabolic Pathways**: - Integration of metabolic pathways within cells tosupport growth, maintenance, and reproduction. Discussion on catabolic and anabolic pathways, energy coupling, and regulation of metabolic activity. 9. **Energy and Homeostasis**: - Importance of energy balance and homeostasis in maintaining cellular function and overall organismal health. Role of feedback mechanisms and metabolic regulation in responding toenergy needs.

10. **Metabolic Adaptations and Regulation**: - Examples of metabolic adaptations in response toenvironmental changes, dietary intake, and physiological demands. Regulation of metabolic pathways through enzyme activity and gene expression. 11. **Emerging Topics in Energy Metabolism**: - Introduction tocurrent research topics and advancements in energy metabolism, such as metabolic disorders, metabolic engineering, and biofuels. 12. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related toenergy forlife, reinforcing understanding of theprinciples governing energy flow and metabolism in biological systems. Chapter 6 provides a comprehensive exploration of energy metabolism within cells, highlighting theinterconnected pathways and regulatory mechanisms that sustain life. It builds upon thefoundational knowledge of cellular dynamics and prepares students forfurther exploration into physiological mechanisms, genetics, and ecological interactions covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 6, feel free toask! Chapter 7: Energy forCells Chapter 7 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Energy forCells," typically delves into themechanisms by which cells acquire and utilize energy fortheir various functions. Here’s an overview of what you might find in this chapter: 1. **Introduction toCellular Energy**: - Overview of theimportance of energy forcellular processes, growth, and maintenance of homeostasis. 2. **Cellular Respiration**: - Detailed exploration of cellular respiration as theprocess by which cells convert chemical energy (glucose) into ATP, theuniversal energy currency of cells. This section typically covers: - **Glycolysis**: Breakdown of glucose into pyruvate, with thenet production of ATP and NADH. - **Krebs Cycle (Citric Acid Cycle)**: Further breakdown of pyruvate in themitochondria togenerate electron carriers (NADH, FADH2) and CO2. - **Electron Transport Chain (ETC)**: Final stage of aerobic respiration, where electron carriers donate electrons togenerate ATP via oxidative phosphorylation. 3. **Anaerobic Respiration and Fermentation**: - Overview of anaerobic pathways (e.g., fermentation) as alternative mechanisms forATP

production in theabsence of oxygen. Comparison toaerobic respiration in terms of efficiency and end products.

4. **Photosynthesis**: - Recapitulation of photosynthesis as theprocess by which plants, algae, and some bacteria convert light energy into chemical energy (glucose) and oxygen. Includes: - **Light Reactions**: Conversion of light energy tochemical energy (ATP, NADPH). - **Calvin Cycle (Dark Reactions)**: Incorporation of carbon dioxide into organic molecules (sugar synthesis). 5. **Metabolic Pathways and Regulation**: - Integration of metabolic pathways within cells tosupport growth, maintenance, and reproduction. Discussion on catabolic (breakdown) and anabolic (synthesis) pathways, energy coupling, and regulation of metabolic activity. 6. **Energy and Homeostasis**: - Importance of energy balance and homeostasis in maintaining cellular function and overall organismal health. Role of feedback mechanisms and metabolic regulation in responding toenergy needs. 7. **Cellular Respiration in Detail**: - Examination of thebiochemical reactions involved in cellular respiration, focusing on therole of enzymes, electron carriers (NADH, FADH2), and theATP synthase complex in ATP production. 8. **Metabolic Adaptations and Regulation**: - Examples of metabolic adaptations in response toenvironmental changes, dietary intake, and physiological demands. Regulation of metabolic pathways through enzyme activity and gene expression. 9. **Energy Efficiency and Conservation**: - Discussion on theefficiency of ATP production through aerobic respiration compared toanaerobic pathways. Energy conservation strategies in biological systems. 10. **Emerging Topics in Cellular Energy**: - Introduction tocurrent research topics and advancements in cellular energy metabolism, such as metabolic disorders, metabolic engineering, and biofuels. 11. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related toenergy forcells, reinforcing understanding of theprinciples governing energy acquisition, utilization, and regulation in biological systems. Chapter 7 provides a comprehensive exploration of cellular energy processes, highlighting theinterconnected pathways and regulatory mechanisms that allow cells tomaintain life and respond totheir environment. It builds upon foundational knowledge of energy metabolism and prepares students forfurther exploration into physiological mechanisms, genetics, and ecological interactions covered in subsequent chapters of thetextbook.

If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 7, feel free toask! Chapter 8: Cellular Reproduction Chapter 8 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Cellular Reproduction," typically focuses on theprocesses of cell division and reproduction. Here’s an overview of what you might find in this chapter: 1. **Introduction toCellular Reproduction**: - Definition of cellular reproduction as theprocess by which cells divide and reproduce, essential forgrowth, repair, and maintenance of multicellular organisms. 2. **The Cell Cycle**: - Detailed exploration of thecell cycle, including its phases: - **Interphase**: G1 phase (cell growth), S phase (DNA replication), G2 phase (preparation fordivision). - **Mitotic Phase**: Mitosis (nuclear division) and cytokinesis (division of thecytoplasm). 3. **Regulation of theCell Cycle**: - Mechanisms and checkpoints that regulate thecell cycle, ensuring accurate DNA replication, mitosis, and proper cell division. 4. **Mitosis**: - Step-by-step explanation of mitosis, including prophase, metaphase, anaphase, and telophase. Role of microtubules, spindle fibers, and centrioles in chromosome segregation and nuclear division. 5. **Meiosis**: - Overview of meiosis as a specialized form of cell division that produces gametes (sperm and eggs) with half thechromosome number of theparent cell. Comparison of meiosis I and meiosis II. 6. **Sexual and Asexual Reproduction**: - Comparison of sexual reproduction (involving gametes and genetic recombination) and asexual reproduction (e.g., binary fission, budding). Advantages and disadvantages of each reproductive strategy. 7. **Cell Cycle Regulation and Cancer**: - Explanation of how disruptions in cell cycle regulation can lead tocancerous growth. Causes of cancer (mutations, environmental factors) and strategies forcancer prevention and treatment. 8. **Regulation of Cell Division**: - Discussion on therole of regulatory proteins (cyclins, cyclin-dependent kinases) in controlling thetiming and progression of thecell cycle.

9. **Stem Cells and Differentiation**:

- Introduction tostem cells, their properties (pluripotent, multipotent) and roles in development, tissue repair, and regenerative medicine. 10. **Cellular Senescence and Aging**: - Overview of cellular senescence, telomeres, and their role in aging and age-related diseases. Relationship between cellular reproduction and longevity. 11. **Emerging Topics in Cellular Reproduction**: - Introduction tocurrent research topics and advancements in cellular reproduction, such as reproductive cloning, induced pluripotent stem cells, and regenerative medicine. 12. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related tocellular reproduction, reinforcing understanding of theprocesses and significance of cell division in biological systems. Chapter 8 provides a comprehensive exploration of cellular reproduction, highlighting themechanisms and regulation of cell division, theimportance of genetic diversity through sexual reproduction, and theimplications of cell cycle abnormalities in health and disease. It builds upon foundational knowledge of cell structure and metabolism and prepares students forfurther exploration into genetics, developmental biology, and physiological mechanisms covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 8, feel free toask! Chapter 9: Meiosis and theGenetic Basis of Sexual Reproduction Chapter 9 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Meiosis and theGenetic Basis of Sexual Reproduction," typically focuses on theprocesses of meiosis, genetic variation, and theroles these play in sexual reproduction. Here’s an overview of what you might find in this chapter: 1. **Introduction toMeiosis**: - Definition of meiosis as a specialized type of cell division that produces haploid gametes (sperm and eggs) from diploid germ cells. 2. **Purpose of Meiosis**: - Explanation of thebiological significance of meiosis in sexual reproduction, including thegeneration of genetic diversity and thereduction of chromosome number. 3. **Comparison of Meiosis and Mitosis**: - Contrast between mitosis and meiosis in terms of: - Number of divisions (one in mitosis, two in meiosis). - Production of daughter cells (genetically identical in mitosis, genetically variable in

meiosis). - Role in multicellular organisms (growth and repair in mitosis, gamete production in meiosis).

4. **Phases of Meiosis**: - Detailed explanation of thestages of meiosis: - **Meiosis I**: Prophase I (crossing over and synapsis), metaphase I, anaphase I, telophase

I. - **Meiosis II**: Similar tomitosis but with haploid cells. 5. **Genetic Variation and Crossing Over**: - Mechanisms that contribute togenetic diversity during meiosis, including crossing over (exchange of genetic material between homologous chromosomes) and independent assortment of chromosomes. 6. **Fertilization and Genetic Diversity**: - How fertilization combines genetic material from two parents togenerate unique genetic combinations in offspring. 7. **Mendelian Genetics and Meiosis**: - Integration of Mendelian principles (laws of segregation and independent assortment) with meiotic processes toexplain inheritance patterns. 8. **Sex Chromosomes and Sex Determination**: - Explanation of sex determination systems, including XX/XY (mammals), ZZ/ZW (birds, some reptiles), and environmental factors (temperature-dependent sex determination). 9. **Genetic Disorders and Chromosomal Abnormalities**: - Overview of genetic disorders caused by errors in meiosis, such as nondisjunction (failure of chromosomes toseparate properly), trisomies (e.g., Down syndrome), and monosomies. 10. **Human Reproduction and Gametogenesis**: - Overview of human reproductive anatomy, gamete production (spermatogenesis and oogenesis), and theroles of hormones (e.g., testosterone, estrogen) in reproductive development. 11. **Emerging Topics in Meiosis and Reproduction**: - Introduction tocurrent research topics and advancements in meiosis, reproductive technologies (e.g., in vitro fertilization, gene editing), and ethical considerations. 12. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related tomeiosis and thegenetic basis of sexual reproduction, reinforcing understanding of theprocesses that underpin genetic diversity and inheritance. Chapter 9 provides a comprehensive exploration of meiosis, genetic variation, and thegenetic basis of sexual reproduction. It builds upon foundational knowledge of cell division (covered in Chapter 8) and prepares students

forfurther exploration into genetics, developmental biology, and evolutionary processes covered in subsequent chapters of thetextbook.

If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 9, feel free toask! Chapter 10 Chapter 10 typically covers "Patterns of Inheritance" in biology or genetics. Here's a general overview of what this chapter often includes: 1. **Mendelian Genetics**: It starts with thebasic principles of inheritance as discovered by Gregor Mendel, such as dominant and recessive alleles, and thelaws of segregation and independent assortment. 2. **Extensions of Mendelian Genetics**: - **Incomplete Dominance**: Where neither allele is completely dominant. - **Codominance**: Where both alleles contribute tothephenotype. - **Multiple Alleles**: Genes that have more than two alleles. - **Polygenic Inheritance**: Traits influenced by multiple genes. 3. **Sex-linked Inheritance**: Inheritance patterns where genes are located on thesex chromosomes (X and Y chromosomes). 4. **Pedigree Analysis**: How tointerpret family trees todeduce patterns of inheritance and predict probabilities of genetic traits in offspring. 5. **Non-Mendelian Inheritance**: Includes exceptions toMendel's laws such as epistasis (interaction between genes) and environmental influences on gene expression. 6. **Genetic Disorders**: Examples of genetic diseases and disorders, and how they are inherited. 7. **Genetic Counseling**: therole of genetic counselors in helping individuals and families understand and cope with genetic disorders and risk factors. This chapter is crucial in understanding how traits are passed from one generation tothenext and thecomplexities involved in genetic inheritance beyond thesimple dominant and recessive traits initially described by Mendel. Chapter 11 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "The Instructions forLife: DNA and RNA," typically explores themolecular basis of genetic information storage and expression. Here’s an overview of what you might find in this chapter: 1. **Introduction toDNA and RNA**: - Definition of DNA (deoxyribonucleic acid) and RNA (ribonucleic acid) as nucleic acids that

store and transmit genetic information in living organisms. 2. **Structure of DNA**: - Detailed examination of thedouble helix structure of DNA, including:

- **Nucleotides**: Composition of DNA nucleotides (adenine, thymine, cytosine, guanine) and their complementary base pairing. - **Sugar-Phosphate Backbone**: Phosphodiester bonds linking nucleotides. - **Antiparallel Strands**: Orientation of DNA strands in opposite directions. 3. **DNA Replication**: - Overview of theprocess by which DNA makes copies of itself before cell division: - **Enzymes**: Role of enzymes (e.g., DNA polymerase, helicase) in unwinding and replicating DNA strands. - **Semi-conservative Replication**: Preservation of one original DNA strand in each new double helix. 4. **RNA Structure and Function**: - Comparison of RNA with DNA in terms of structure and function: - **Types of RNA**: mRNA (messenger RNA), tRNA (transfer RNA), rRNA (ribosomal RNA), and their roles in protein synthesis. - **Transcription**: Process of synthesizing mRNA from a DNA template (gene expression). 5. **Genetic Code and Protein Synthesis**: - Explanation of thegenetic code as thecorrespondence between nucleotide triplets (codons) and amino acids. Steps in protein synthesis: - **Transcription**: Synthesis of mRNA from DNA. - **Translation**: Conversion of mRNA sequence into a specific sequence of amino acids in a protein. 6. **Regulation of Gene Expression**: - Mechanisms by which cells control when and how genes are turned on or off, including: - **Promoters and Enhancers**: DNA sequences that regulate transcription. - **Transcription Factors**: Proteins that bind toregulatory sequences tocontrol gene expression. - **Epigenetic Modifications**: Changes in gene expression without altering DNA sequence (e.g., DNA methylation, histone modification). 7. **Mutations and Genetic Variation**: - Types of mutations (e.g., point mutations, insertions, deletions) and their effects on DNA sequence and protein function. Role of mutations in evolution and genetic diversity. 8. **DNA Technology and Genetic Engineering**: - Applications of DNA technology, including polymerase chain reaction (PCR), gene cloning, genetic modification of organisms (GMOs), and gene therapy. 9. **Genomics and Personalized Medicine**: - Introduction togenomics as thestudy of whole genomes and its applications in understanding diseases, predicting risks, and developing personalized treatments. 10. **Emerging Topics in DNA and RNA**:

- Introduction tocurrent research topics and advancements in DNA and RNA research, such as CRISPR-Cas9 genome editing, RNA interference (RNAi), and synthetic biology. 11. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related toDNA and RNA, reinforcing understanding of themolecular basis of genetic information and its expression. Chapter 11 provides a comprehensive exploration of themolecular mechanisms underlying genetic information storage, transmission, and expression. It builds upon foundational knowledge of cellular processes and prepares students forfurther exploration into molecular genetics, genomics, and biotechnology covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 11, feel free toask! Chapter 12 Chapter 12: Biotechnology and Genomics Chapter 12 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Biotechnology and Genomics," typically delves into theapplications and implications of biotechnology in modern biology, with a focus on genomics. Here’s an overview of what you might find in this chapter: 1. **Introduction toBiotechnology**: - Definition of biotechnology as theuse of biological systems, organisms, or processes todevelop products or applications forvarious purposes. 2. **Tools of Biotechnology**: - Overview of key tools and techniques used in biotechnology, including: - **Recombinant DNA Technology**: Techniques formanipulating DNA, such as gene cloning, PCR (Polymerase Chain Reaction), and gene editing (e.g., CRISPR-Cas9). - **DNA Sequencing**: Methods fordetermining theprecise order of nucleotides in a DNA molecule. - **Genomic Libraries**: Collections of cloned DNA fragments representing an organism's entire genome. 3. **Applications of Biotechnology**: - Exploration of practical applications of biotechnology in various fields: - **Medicine**: Gene therapy, personalized medicine, production of therapeutic proteins (e.g., insulin). - **Agriculture**: Genetically modified organisms (GMOs), crop improvement, pest resistance. - **Industry**: Bioremediation, biofuels, enzyme production. - **Forensics**: DNA fingerprinting, forensic analysis.

4. **Genomics and Human Health**: - Introduction togenomics as thestudy of whole genomes, including:

- **Human Genome Project**: Overview, goals, and impact on understanding human genetics and disease. - **Genomic Medicine**: Applications of genomics in diagnosis, treatment, and prevention of diseases (e.g., cancer genomics, pharmacogenomics). 5. **Ethical and Social Issues in Biotechnology**: - Discussion on ethical considerations related tobiotechnological advancements, including: - **Genetic Privacy**: Issues surrounding theuse and protection of genetic information. - **Bioethics**: Considerations of fairness, access, and thepotential consequences of biotechnological applications. 6. **Regulation of Biotechnology**: - Overview of regulatory frameworks and agencies responsible foroverseeing biotechnological research, development, and applications (e.g., FDA, USDA). 7. **Emerging Technologies in Biotechnology**: - Introduction tocurrent and emerging technologies in biotechnology and genomics, such as synthetic biology, CRISPR-based genome editing, and bioinformatics. 8. **Impact of Biotechnology on Society**: - Examination of thebroader impacts of biotechnology on society, including economic implications, job creation, and public perceptions. 9. **Future Directions in Biotechnology**: - Speculation on future trends and potential breakthroughs in biotechnology, including applications in space exploration, environmental sustainability, and beyond. 10. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related tobiotechnology and genomics, reinforcing understanding of theapplications, implications, and ethical considerations associated with biotechnological advancements. Chapter 12 provides a comprehensive exploration of thediverse applications and ethical considerations of biotechnology, with a focus on genomics and its impact on various aspects of human health, agriculture, industry, and society. It builds upon foundational knowledge of molecular genetics and prepares students forfurther exploration into advanced topics in genetics, biotechnology, and bioethics covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 12, feel free toask! Chapter 13: Mutations and Genetic Testing Chapter 13 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Mutations and Genetic Testing," typically focuses on thenature of mutations, their causes, consequences, and therole of genetic testing in

identifying genetic disorders. Here’s an overview of what you might find in this chapter:

1. **Introduction toMutations**: - Definition of mutations as changes in theDNA sequence that can alter thestructure and function of proteins encoded by genes. 2. **Types of Mutations**: - Explanation of different types of mutations: - **Point Mutations**: Changes in a single nucleotide (substitutions, insertions, deletions). - **Chromosomal Mutations**: Structural changes in chromosomes (e.g., deletions, duplications, inversions, translocations). - **Mutagens**: Environmental factors (chemicals, radiation) that can increase therate of mutations. 3. **Causes of Mutations**: - Overview of spontaneous mutations (arising from errors in DNA replication or repair) and induced mutations (caused by mutagens). 4. **Consequences of Mutations**: - Impact of mutations on protein structure and function: - **Silent Mutations**: No change in amino acid sequence. - **Missense Mutations**: Change in one amino acid. - **Nonsense Mutations**: Premature termination of protein synthesis. - **Frameshift Mutations**: Insertion or deletion of nucleotides, leading toa shift in thereading frame. 5. **Genetic Testing**: - Definition of genetic testing as theanalysis of DNA, RNA, or chromosomes todetect genetic variations associated with inherited disorders or predispositions todiseases. 6. **Types of Genetic Testing**: - Overview of different methods used in genetic testing: - **Diagnostic Testing**: Identification of a specific genetic condition in an individual. - **Carrier Testing**: Identification of individuals carrying recessive alleles forgenetic disorders. - **Predictive and Presymptomatic Testing**: Assessment of risk fordeveloping genetic conditions later in life. - **Prenatal Testing**: Screening forgenetic disorders in fetuses during pregnancy. - **Newborn Screening**: Testing forgenetic disorders shortly after birth. 7. **Ethical and Social Issues in Genetic Testing**: - Discussion on ethical considerations related togenetic testing, including privacy, confidentiality, informed consent, and implications forindividuals and families. 8. **Genetic Counseling**: - Role of genetic counselors in interpreting genetic test results, providing information, and supporting decision-making regarding genetic testing and family planning.

9. **Genetic Disorders and Public Health**: - Impact of genetic testing on public health initiatives, disease prevention, and management of genetic disorders. 10. **Emerging Technologies in Genetic Testing**: - Introduction toadvances in genetic testing technologies, such as next-generation sequencing (NGS), whole exome sequencing (WES), and direct-to-consumer genetic testing. 11. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related tomutations and genetic testing, reinforcing understanding of thecauses, consequences, applications, and ethical considerations associated with genetic variation and testing. Chapter 13 provides a comprehensive exploration of mutations, genetic testing technologies, and their implications in diagnosing, preventing, and managing genetic disorders. It builds upon foundational knowledge of molecular genetics and prepares students forfurther exploration into personalized medicine, genetic counseling, and ethical issues in genetics covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 13, feel free toask! Chapter 14 Chapter 14 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Darwin and Evolution," typically explores theprinciples of evolution, its mechanisms, and thecontributions of Charles Darwin toevolutionary theory. Here’s an overview of what you might find in this chapter: 1. **Introduction toEvolution**: - Definition of evolution as theprocess of change over time in populations of organisms, leading tothediversity of life on Earth. 2. **Darwin's Contributions**: - Overview of Charles Darwin's observations and insights that led tothedevelopment of thetheory of evolution by natural selection: - **Voyage of theBeagle**: Darwin's travels and observations of biodiversity and geological formations. - **Natural Selection**: Mechanism proposed by Darwin toexplain how evolution occurs through differential survival and reproduction of organisms with advantageous traits. 3. **Evidence forEvolution**: - Examination of various lines of evidence supporting thetheory of evolution: - **Fossil Record**: Transitional forms and patterns of species change over time.

- **Biogeography**: Distribution of species and similarities among organisms on different continents.

- **Comparative Anatomy**: Homologous structures and vestigial organs among different species. - **Molecular Biology**: Similarities in DNA, RNA, and protein sequences among organisms indicating common ancestry. 4. **Mechanisms of Evolution**: - Exploration of processes that drive evolutionary change: - **Natural Selection**: Differential survival and reproduction of individuals with advantageous traits. - **Genetic Drift**: Random changes in allele frequencies in small populations. - **Gene Flow**: Movement of genes between populations through migration. - **Mutation**: Source of new genetic variation. 5. **Modern Synthesis of Evolutionary Theory**: - Integration of Darwinian evolution with genetics (population genetics), explaining how genetic variation and natural selection shape evolutionary patterns. 6. **Patterns and Rates of Evolution**: - Examination of evolutionary patterns, including: - **Adaptive Radiation**: Diversification of a single ancestral species into a variety of forms in response todifferent environmental niches. - **Convergent Evolution**: Independent evolution of similar traits in different lineages. - **Punctuated Equilibrium**: Periods of rapid evolutionary change followed by long periods of stability. 7. **Human Evolution**: - Overview of human evolution, including fossil evidence (e.g., Australopithecus, Homo species) and genetic studies revealing relationships among modern human populations. 8. **Evolutionary Mechanisms and Adaptation**: - Discussion on how evolutionary mechanisms (natural selection, genetic drift) contribute toadaptation of organisms totheir environments. 9. **Evolution and Speciation**: - Explanation of speciation as theprocess by which new species arise, including allopatric, sympatric, and parapatric speciation. 10. **Emerging Topics in Evolutionary Biology**: - Introduction tocurrent research topics and advancements in evolutionary biology, such as evolutionary developmental biology (evo-devo), molecular evolution, and thestudy of evolutionary processes in response toenvironmental changes. 11. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related toDarwin and evolution, reinforcing understanding of theprinciples, mechanisms, and evidence supporting evolutionary theory.

Chapter 14 provides a comprehensive exploration of evolutionary theory, Darwin's contributions, and themechanisms that drive evolutionary change. It builds upon foundational knowledge of genetics and prepares students forfurther exploration into ecology, biodiversity, and evolutionary biology covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 14, feel free toask! Chapter 15: Evolution on a Small Scale Chapter 15 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Evolution on a Small Scale," typically focuses on evolutionary processes that occur within populations and species. Here’s an overview of what you might find in this chapter: 1. **Introduction toMicroevolution**: - Definition of microevolution as evolutionary change occurring within populations over relatively short periods of time. 2. **Population Genetics**: - Overview of population genetics, which studies thedistribution and change of allele frequencies in populations: - **Gene Pool**: Total collection of alleles in a population. - **Hardy-Weinberg Principle**: Mathematical model describing allele frequencies in a nonevolving population. 3. **Factors Influencing Microevolution**: - Discussion on themechanisms that drive microevolutionary changes: - **Natural Selection**: Differential survival and reproduction of individuals with advantageous traits. - **Genetic Drift**: Random changes in allele frequencies due tochance events, more pronounced in small populations. - **Gene Flow**: Movement of genes between populations through migration. - **Mutation**: Source of new genetic variation. 4. **Types of Natural Selection**: - Exploration of different types of natural selection: - **Stabilizing Selection**: Selection against extremes, favoring intermediate phenotypes. - **Directional Selection**: Shift toward one extreme phenotype in response toenvironmental change. - **Disruptive Selection**: Selection favoring both extremes, leading topolymorphism. 5. **Adaptation and Fitness**: - Definition of adaptation as theprocess by which populations become better suited totheir environments through natural selection. Measurement of fitness as therelative reproductive success of individuals with a particular genotype.

6. **Genetic Variation and Polymorphism**: - Explanation of genetic variation within populations, including: - **Polygenic Traits**: Traits influenced by multiple genes. - **Quantitative Genetics**: Study of complex traits influenced by multiple genes and environmental factors. 7. **Speciation and Reproductive Isolation**: - Introduction tospeciation as theprocess by which new species arise, including mechanisms of reproductive isolation: - **Prezygotic Barriers**: Prevent mating or fertilization between species. - **Postzygotic Barriers**: Reduce viability or fertility of hybrid offspring. 8. **Patterns of Microevolution**: - Examination of evolutionary patterns observed in natural populations, including: - **Selective Pressures**: Environmental factors influencing adaptation. - **Population Bottlenecks**: Reduction in population size leading togenetic drift. - **Founder Effect**: Genetic drift in small founding populations. 9. **Human Impact on Microevolution**: - Discussion on how human activities (e.g., habitat destruction, pollution, climate change) can influence microevolutionary processes in natural populations. 10. **Emerging Topics in Microevolution**: - Introduction tocurrent research topics and advancements in microevolutionary studies, such as evolutionary responses torapid environmental changes and therole of epigenetics in evolution. 11. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related tomicroevolution, reinforcing understanding of themechanisms and patterns of evolutionary change within populations. Chapter 15 provides a comprehensive exploration of microevolutionary processes, including natural selection, genetic drift, gene flow, and their roles in shaping genetic diversity and adaptation within populations. It builds upon foundational knowledge of genetics and evolutionary theory, preparing students forfurther exploration into macroevolution, ecological genetics, and conservation biology covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 15, feel free toask! Chapter 16: Evolution on a Large Scale Chapter 16 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Evolution on a Large Scale," typically explores evolutionary processes that

occur over longer time scales and across larger taxonomic groups. Here’s an overview of what you might find in this chapter:

1. **Introduction toMacroevolution**: - Definition of macroevolution as evolutionary patterns and processes that occur above thespecies level, leading tothediversification of life forms over geologic time scales. 2. **Speciation**: - Detailed exploration of speciation, theprocess by which new species arise: - **Allopatric Speciation**: Geographic isolation leading toreproductive isolation. - **Sympatric Speciation**: Speciation occurring within thesame geographic area due tofactors like polyploidy or habitat differentiation. - **Parapatric Speciation**: Speciation occurring in adjacent but different habitats. 3. **Patterns of Macroevolution**: - Examination of major patterns and trends observed in thefossil record and biological diversity: - **Adaptive Radiation**: Diversification of a single ancestral species into a variety of ecological niches. - **Extinction Events**: Mass extinctions and their impact on biodiversity. - **Convergent Evolution**: Independent evolution of similar traits in unrelated lineages. 4. **Evolutionary Trends**: - Analysis of evolutionary trends observed in various taxonomic groups: - **Coevolution**: Reciprocal evolutionary changes between interacting species (e.g., predator-prey, host-parasite). - **Evolutionary Developmental Biology (Evo-devo)**: Study of how changes in developmental processes contribute toevolutionary change. - **Evolution of Complexity**: Emergence of complex traits and biological structures over evolutionary time. 5. **Biogeography**: - Exploration of thedistribution of species and how historical and ecological factors influence patterns of biodiversity: - **Continental Drift**: Movement of continents and its impact on biogeographic patterns. - **Island Biogeography**: Patterns of species diversity on islands influenced by colonization and extinction. 6. **Evolutionary Ecology**: - Integration of evolutionary biology with ecological principles, including: - **Adaptive Radiation**: Ecological opportunities driving speciation. - **Species Interactions**: Coevolutionary relationships and their ecological and evolutionary consequences. 7. **Evolutionary Development**: - Discussion on therole of developmental processes in shaping evolutionary trajectories and patterns of phenotypic variation.

8. **Human Evolution**: - Overview of human evolutionary history, including fossil evidence (e.g., Australopithecus, Homo species) and genetic studies revealing relationships among modern human populations. 9. **Emerging Topics in Macroevolution**: - Introduction tocurrent research topics and advancements in macroevolutionary studies, such as evolutionary responses toclimate change, genomic approaches tounderstanding macroevolution, and therole of evolutionary theory in conservation biology. 10. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related tomacroevolution, reinforcing understanding of thepatterns, processes, and implications of evolution at broader scales. Chapter 16 provides a comprehensive exploration of macroevolutionary processes, including speciation, evolutionary trends, biogeography, and theintegration of evolutionary biology with ecology and developmental biology. It builds upon foundational knowledge of genetics and microevolution, preparing students forfurther exploration into paleontology, evolutionary ecology, and interdisciplinary studies in evolutionary biology covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 16, feel free toask! Chapter 16 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Evolution on a Large Scale," typically explores evolutionary processes that occur over longer time scales and across larger taxonomic groups. Here’s an overview of what you might find in this chapter: 1. **Introduction toMacroevolution**: - Definition of macroevolution as evolutionary patterns and processes that occur above thespecies level, leading tothediversification of life forms over geologic time scales. 2. **Speciation**: - Detailed exploration of speciation, theprocess by which new species arise: - **Allopatric Speciation**: Geographic isolation leading toreproductive isolation. - **Sympatric Speciation**: Speciation occurring within thesame geographic area due tofactors like polyploidy or habitat differentiation. - **Parapatric Speciation**: Speciation occurring in adjacent but different habitats. 3. **Patterns of Macroevolution**: - Examination of major patterns and trends observed in thefossil record and biological diversity: - **Adaptive Radiation**: Diversification of a single ancestral species into a variety of

ecological niches. - **Extinction Events**: Mass extinctions and their impact on biodiversity.

- **Convergent Evolution**: Independent evolution of similar traits in unrelated lineages. 4. **Evolutionary Trends**: - Analysis of evolutionary trends observed in various taxonomic groups: - **Coevolution**: Reciprocal evolutionary changes between interacting species (e.g., predator-prey, host-parasite). - **Evolutionary Developmental Biology (Evo-devo)**: Study of how changes in developmental processes contribute toevolutionary change. - **Evolution of Complexity**: Emergence of complex traits and biological structures over evolutionary time. 5. **Biogeography**: - Exploration of thedistribution of species and how historical and ecological factors influence patterns of biodiversity: - **Continental Drift**: Movement of continents and its impact on biogeographic patterns. - **Island Biogeography**: Patterns of species diversity on islands influenced by colonization and extinction. 6. **Evolutionary Ecology**: - Integration of evolutionary biology with ecological principles, including: - **Adaptive Radiation**: Ecological opportunities driving speciation. - **Species Interactions**: Coevolutionary relationships and their ecological and evolutionary consequences. 7. **Evolutionary Development**: - Discussion on therole of developmental processes in shaping evolutionary trajectories and patterns of phenotypic variation. 8. **Human Evolution**: - Overview of human evolutionary history, including fossil evidence (e.g., Australopithecus, Homo species) and genetic studies revealing relationships among modern human populations. 9. **Emerging Topics in Macroevolution**: - Introduction tocurrent research topics and advancements in macroevolutionary studies, such as evolutionary responses toclimate change, genomic approaches tounderstanding macroevolution, and therole of evolutionary theory in conservation biology. 10. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related tomacroevolution, reinforcing understanding of thepatterns, processes, and implications of evolution at broader scales.

Chapter 16 provides a comprehensive exploration of macroevolutionary processes, including speciation, evolutionary trends, biogeography, and theintegration of evolutionary biology with ecology and developmental biology. It builds upon foundational knowledge of genetics and microevolution, preparing students forfurther exploration into paleontology, evolutionary ecology, and interdisciplinary studies in evolutionary biology covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 16, feel free toask! Chapter 17 Chapter 17 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Viruses, Bacteria, and Protists," typically covers thediversity, structure, functions, and ecological roles of these microorganisms. Here’s an overview of what you might find in this chapter: 1. **Introduction toMicroorganisms**: - Definition and classification of microorganisms as organisms that are too small tobe seen with thenaked eye, including viruses, bacteria, and protists. 2. **Viruses**: - Characteristics of viruses: - **Structure**: Viral components (nucleic acid core and protein coat). - **Reproduction**: Viral replication using host cell machinery (lytic and lysogenic cycles). - **Role in Disease**: Viral infections and human health impacts. 3. **Bacteria**: - Overview of bacterial diversity, structure, and functions: - **Cell Structure**: Prokaryotic cell structure (cell wall, plasma membrane, cytoplasm, genetic material). - **Metabolism**: Modes of nutrition (autotrophs vs. heterotrophs), oxygen requirements (aerobic vs. anaerobic). - **Reproduction**: Binary fission and genetic recombination (transformation, conjugation, transduction). 4. **Bacterial Diversity and Ecology**: - Ecological roles of bacteria: - **Nutrient Cycling**: Decomposition and recycling of organic matter. - **Symbiotic Relationships**: Mutualism, commensalism, and parasitism. - **Pathogenic Bacteria**: Causes of bacterial diseases and mechanisms of infection. 5. **Protists**: - Diversity of protists:

- **Classification**: Protozoa (single-celled heterotrophs) and algae (photosynthetic protists). - **Structure**: Protozoan and algal cell structures and adaptations.

- **Ecological Roles**: Roles in aquatic ecosystems, symbiotic relationships (e.g., coralalgal symbiosis). 6. **Life Cycles and Reproduction of Protists**: - Reproductive strategies among protists: - **Asexual Reproduction**: Binary fission, budding, and spore formation. - **Sexual Reproduction**: Conjugation and other forms of genetic exchange. 7. **Ecological Importance of Protists**: - Contribution of protists toecosystems: - **Primary Production**: Role of photosynthetic protists in food chains. - **Symbiotic Relationships**: Protists in mutualistic and parasitic interactions with other organisms. 8. **Human Health and Disease**: - Impact of microorganisms on human health: - **Pathogenic Viruses and Bacteria**: Viral and bacterial diseases (e.g., influenza, tuberculosis). - **Protozoan Diseases**: Malaria and other parasitic infections caused by protists. 9. **Emerging Infectious Diseases**: - Discussion on factors contributing totheemergence and spread of new infectious diseases (e.g., zoonotic diseases, antibiotic resistance). 10. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related toviruses, bacteria, and protists, reinforcing understanding of their diversity, structures, functions, and ecological roles. Chapter 17 provides a comprehensive exploration of viruses, bacteria, and protists, highlighting their diversity, evolutionary relationships, ecological roles, and impacts on human health and ecosystems. It prepares students forfurther exploration into microbiology, infectious diseases, and environmental microbiology covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 17, feel free toask! Chapter 18: Plants and Fungi Chapter 18 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Plants and Fungi," typically covers thecharacteristics, diversity, adaptations, and ecological roles of plants and fungi. Here’s an overview of what you might find in this chapter: 1. **Introduction toPlants and Fungi**:

- Definition and classification of plants and fungi as multicellular eukaryotic organisms with distinct characteristics and life cycles.

2. **Plant Diversity**: - Overview of plant diversity: - **Non-Vascular Plants**: Characteristics of mosses, liverworts, and hornworts. - **Seedless Vascular Plants**: Characteristics of ferns and their relatives. - **Seed Plants**: Gymnosperms (e.g., conifers) and angiosperms (flowering plants). 3. **Plant Structure and Function**: - Morphological and physiological adaptations of plants: - **Roots, Stems, and Leaves**: Functions and adaptations forabsorption, support, and photosynthesis. - **Reproductive Structures**: Flowers, fruits, seeds, and pollen. 4. **Plant Reproduction and Life Cycles**: - Alternation of generations in plants: - **Gametophyte and Sporophyte**: Structures and functions in thelife cycles of mosses, ferns, gymnosperms, and angiosperms. - **Pollination and Fertilization**: Mechanisms of pollen transfer and fertilization in flowering plants. 5. **Plant Physiology**: - Physiological processes in plants: - **Photosynthesis**: Light reactions and Calvin cycle. - **Transport**: Water and nutrient uptake (xylem and phloem transport). - **Hormonal Regulation**: Role of plant hormones in growth, development, and responses toenvironmental stimuli. 6. **Ecology of Plants**: - Ecological roles and interactions of plants in ecosystems: - **Primary Production**: Role of plants as primary producers in food webs. - **Plant-Animal Interactions**: Pollination, seed dispersal, and herbivory. - **Plant Adaptations toEnvironmental Factors**: Adaptations tolight, water availability, temperature, and soil conditions. 7. **Fungi Diversity**: - Overview of fungal diversity and classification: - **Mycorrhizal Fungi**: Symbiotic relationships with plant roots. - **Saprophytic Fungi**: Decomposition and nutrient recycling in ecosystems. - **Pathogenic Fungi**: Fungal diseases in plants and animals. 8. **Fungal Structure and Function**: - Morphological features and adaptations of fungi: - **Hyphae and Mycelium**: Structure and growth patterns. - **Reproductive Structures**: Spores, sporangia, and fruiting bodies. 9. **Fungal Reproduction and Life Cycles**: - Modes of reproduction in fungi:

- **Asexual Reproduction**: Spore formation and budding. - **Sexual Reproduction**: Fusion of haploid hyphae, formation of dikaryotic and diploid stages. 10. **Fungal Physiology**: - Physiological processes in fungi: - **Nutrient Absorption**: Extracellular digestion and absorption of nutrients. - **Mycorrhizal Associations**: Role of fungi in nutrient uptake and exchange with plant roots. - **Environmental Responses**: Fungal responses tolight, moisture, and pH levels. 11. **Ecology of Fungi**: - Ecological roles and interactions of fungi in ecosystems: - **Decomposition**: Role in nutrient cycling and organic matter decomposition. - **Symbiotic Relationships**: Mycorrhizal associations with plants, lichens (fungus-algae symbiosis). 12. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related toplants and fungi, reinforcing understanding of their diversity, structures, functions, and ecological roles. Chapter 18 provides a comprehensive exploration of plants and fungi, highlighting their structural diversity, physiological adaptations, reproductive strategies, and ecological interactions. It prepares students forfurther exploration into plant biology, mycology, ecology, and environmental sciences covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 18, feel free toask! Chapter 19 Chapter 19 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Animals," typically covers thediversity, characteristics, adaptations, and ecological roles of animals. Here’s an overview of what you might find in this chapter: 1. **Introduction toAnimals**: - Definition and classification of animals as multicellular, heterotrophic organisms with diverse body plans and life cycles. 2. **Animal Diversity**: - Overview of animal diversity based on major phyla: - **Invertebrates**: Characteristics and examples of major groups (e.g., sponges, cnidarians, mollusks, annelids, arthropods).

- **Vertebrates**: Characteristics and examples of major groups (e.g., fish, amphibians, reptiles, birds, mammals). 3. **Animal Form and Function**:

- Morphological and physiological adaptations of animals: - **Body Plans**: Symmetry (radial vs. bilateral), segmentation, and cephalization. - **Tissues and Organs**: Specialized structures and functions (e.g., nervous system, digestive system, circulatory system). - **Skeletal Systems**: Endoskeletons, exoskeletons, and hydrostatic skeletons. 4. **Animal Reproduction and Development**: - Modes of reproduction in animals: - **Sexual Reproduction**: Internal and external fertilization, development of embryos. - **Asexual Reproduction**: Regeneration, budding, and parthenogenesis. - **Life Cycles**: Alternation of generations, metamorphosis in insects and amphibians. 5. **Animal Behavior**: - Behavioral adaptations and ecological interactions: - **Feeding Behaviors**: Herbivores, carnivores, omnivores, and filter feeders. - **Reproductive Behaviors**: Courtship rituals, mate selection, and parental care. - **Social Behaviors**: Group behaviors, communication, and cooperation. 6. **Animal Physiology**: - Physiological processes in animals: - **Nutrition**: Digestive processes and nutrient absorption. - **Respiration**: Respiratory structures and gas exchange mechanisms. - **Circulation**: Circulatory systems and transport of gases, nutrients, and wastes. - **Excretion**: Excretory organs and regulation of water and electrolyte balance. 7. **Ecology of Animals**: - Ecological roles and interactions of animals in ecosystems: - **Predator-Prey Relationships**: Food webs and trophic interactions. - **Symbiotic Relationships**: Mutualism, commensalism, and parasitism. - **Migration and Movement**: Animal movements and their ecological significance. 8. **Animal Adaptations toEnvironments**: - Adaptations todiverse habitats and environmental conditions: - **Desert Adaptations**: Water conservation and thermoregulation. - **Aquatic Adaptations**: Marine and freshwater adaptations forbuoyancy, osmoregulation, and respiration. - **Polar Adaptations**: Cold adaptation and insulation. 9. **Human Impact on Animal Populations**: - Impact of human activities on animal populations and biodiversity: - **Habitat Destruction**: Loss of habitats and fragmentation. - **Overexploitation**: Hunting, fishing, and wildlife trade. - **Pollution and Climate Change**: Effects on animal habitats and ecosystems. 10. **Conservation Biology**: - Principles and practices of conservation biology toprotect animal species and ecosystems:

- **Endangered Species**: Conservation strategies and restoration efforts. - **Protected Areas**: National parks, reserves, and wildlife sanctuaries. - **Sustainable Practices**: Sustainable development and habitat conservation. 11. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related toanimals, reinforcing understanding of their diversity, structures, functions, adaptations, and ecological roles. Chapter 19 provides a comprehensive exploration of animals, highlighting their evolutionary diversity, physiological adaptations, behavioral strategies, and ecological interactions. It prepares students forfurther exploration into animal biology, ecology, behavior, and conservation sciences covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 19, feel free toask! Chapter 20 Chapter 20 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Plant Anatomy and Growth," typically covers theinternal structure, tissues, growth processes, and adaptations of plants. Here’s an overview of what you might find in this chapter: 1. **Introduction toPlant Anatomy**: - Overview of plant anatomy as thestudy of internal structures and tissues of plants. 2. **Plant Cells and Tissues**: - Structure and functions of plant cells and tissues: - **Cell Types**: Parenchyma, collenchyma, sclerenchyma, xylem, phloem, epidermis, and guard cells. - **Tissue Systems**: Dermal tissue, ground tissue, and vascular tissue. 3. **Root Structure and Function**: - Morphology and functions of roots: - **Root Anatomy**: Root hairs, root cap, cortex, and vascular cylinder (stele). - **Functions**: Absorption of water and minerals, anchorage, and storage. 4. **Stem Structure and Function**: - Morphology and functions of stems: - **Stem Anatomy**: Epidermis, cortex, vascular bundles (xylem and phloem), and pith. - **Functions**: Support, transport of water and nutrients, and storage. 5. **Leaf Structure and Function**:

- Morphology and functions of leaves: - **Leaf Anatomy**: Epidermis, mesophyll (palisade and spongy layers), stomata, and vascular bundles. - **Functions**: Photosynthesis, gas exchange (transpiration and respiration), and storage.

6. **Plant Growth and Development**: - Processes of plant growth: - **Meristems**: Apical, lateral (vascular and cork cambium), and intercalary meristems. - **Primary Growth**: Lengthening of roots and shoots. - **Secondary Growth**: Thickening of stems and roots due tovascular and cork cambium activity. 7. **Plant Hormones**: - Role of plant hormones in growth and development: - **Auxins**: Role in apical dominance, phototropism, and root growth. - **Gibberellins**: Stem elongation and seed germination. - **Cytokinins**: Cell division and lateral bud growth. - **Ethylene**: Fruit ripening and senescence. - **Abscisic Acid**: Dormancy and stress responses. 8. **Plant Responses toEnvironmental Stimuli**: - Plant adaptations and responses toenvironmental factors: - **Photoperiodism**: Flowering responses today length. - **Tropisms**: Growth responses tolight (phototropism), gravity (gravitropism), and touch (thigmotropism). - **Plant Movements**: Nastic movements and responses toenvironmental cues. 9. **Plant Adaptations toEnvironmental Stress**: - Adaptations of plants toextreme environmental conditions: - **Water Conservation**: Adaptations in desert plants (e.g., succulence, CAM photosynthesis). - **Cold and Heat Tolerance**: Adaptations in polar and desert plants. - **Salt Tolerance**: Adaptations in halophytes. 10. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related toplant anatomy and growth, reinforcing understanding of plant structures, functions, growth processes, and adaptations. Chapter 20 provides a comprehensive exploration of plant anatomy and growth, highlighting thestructural diversity, physiological adaptations, and growth mechanisms that enable plants tothrive in diverse environments. It prepares students forfurther exploration into plant physiology, ecology, and agriculture covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 20, feel free toask!

Chapter 21

Chapter 21 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Plant Responses and Reproduction," typically covers how plants respond toenvironmental stimuli and thevarious mechanisms of plant reproduction. Here’s an overview of what you might find in this chapter: 1. **Plant Responses toEnvironmental Stimuli**: - **Photoperiodism**: Plant responses today length, influencing flowering and other developmental processes. - **Tropisms**: Directional growth responses toenvironmental stimuli: - **Phototropism**: Growth towards or away from light. - **Gravitropism**: Growth response togravity. - **Thigmotropism**: Growth response totouch. - **Plant Movements**: Nastic movements in response toenvironmental cues (e.g., leaf movements in Mimosa pudica). 2. **Plant Reproduction**: - **Flowering Plants (Angiosperms)**: - **Flower Structure**: Parts of theflower (sepals, petals, stamens, carpels). - **Pollination**: Transfer of pollen from anther tostigma. - **Fertilization**: Fusion of male gamete (pollen) with female gamete (egg) toform a zygote. - **Seed Development**: Formation of seed from fertilized ovule. - **Fruit Formation**: Development of fruit from mature ovary. - **Seed Dispersal**: Mechanisms fordispersing seeds away from theparent plant (e.g., wind, water, animals). 3. **Asexual Reproduction in Plants**: - **Vegetative Propagation**: Asexual reproduction through plant parts (e.g., runners, bulbs, tubers). - **Cloning**: Artificial methods of asexual propagation (e.g., cuttings, tissue culture). 4. **Plant Hormones and Growth Regulation**: - **Auxins**: Role in apical dominance, phototropism, and root growth. - **Gibberellins**: Stem elongation and seed germination. - **Cytokinins**: Cell division and lateral bud growth. - **Ethylene**: Fruit ripening and senescence. - **Abscisic Acid**: Dormancy and stress responses. - **Plant Responses toStress**: Hormonal and physiological responses toenvironmental stresses (e.g., drought, salinity). 5. **Plant Life Cycles and Alternation of Generations**: - **Alternation of Generations**: Alternating between haploid (gametophyte) and diploid (sporophyte) generations in plant life cycles. - **Bryophytes**: Life cycle of mosses and liverworts. - **Ferns and Seed Plants**: Life cycle of ferns, gymnosperms, and angiosperms.

6. **Reproductive Strategies in Non-Flowering Plants**: - **Seedless Plants**: Reproduction in ferns and other seedless vascular plants. - **Gymnosperms**: Life cycle of conifers and other gymnosperms. 7. **Human Impact on Plant Reproduction**: - **Agricultural Practices**: Use of hormones and techniques forenhancing plant reproduction and yield. - **Pollination Crisis**: Factors affecting pollinator populations and implications forcrop pollination. 8. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related toplant responses and reproduction, reinforcing understanding of plant adaptations, reproductive strategies, and therole of hormones in plant growth and development. Chapter 21 provides a comprehensive exploration of how plants respond totheir environment and thevarious mechanisms through which they reproduce, from flowering plants tonon- flowering plants. It prepares students forfurther exploration into plant physiology, ecology, and agriculture covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 21, feel free toask! Chapter 22 Chapter 22 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Organization of theAnimal Body," typically covers thestructure, organization, and physiological systems of animals. Here’s an overview of what you might find in this chapter: 1. **Introduction toAnimal Structure and Organization**: - Overview of animal diversity and body plans. - Introduction toanimal tissues and organs. 2. **Animal Tissues**: - Types of animal tissues: - **Epithelial Tissue**: Functions, types (simple, stratified), and locations (e.g., skin, lining of organs). - **Connective Tissue**: Functions, types (e.g., loose connective tissue, adipose tissue, cartilage, bone), and extracellular matrix. - **Muscle Tissue**: Types (skeletal, cardiac, smooth), functions, and contraction mechanisms. - **Nervous Tissue**: Neurons and glial cells, functions, and transmission of nerve impulses. 3. **Animal Organ Systems**: - **Integumentary System**: Structure and functions of skin and its appendages (e.g., hair,

nails, glands). - **Skeletal System**: Structure and functions of bones, cartilage, and joints.

- **Muscular System**: Types of muscles, functions, and muscle contraction. - **Nervous System**: Structure (brain, spinal cord, nerves) and functions (sensory input, integration, motor output). - **Endocrine System**: Glands (e.g., pituitary, thyroid, adrenal glands), hormones, and regulatory functions. - **Cardiovascular System**: Heart, blood vessels (arteries, veins, capillaries), and blood circulation. - **Lymphatic and Immune Systems**: Lymphatic vessels, lymph nodes, immune cells, and immune responses. - **Respiratory System**: Structure and functions of respiratory organs (e.g., lungs, gills), gas exchange, and breathing mechanisms. - **Digestive System**: Organs (e.g., mouth, stomach, intestines, liver), digestion, absorption of nutrients, and waste elimination. - **Excretory System**: Kidneys, urinary system, filtration, and regulation of water and electrolyte balance. - **Reproductive System**: Male and female reproductive organs, gamete production, and reproductive processes. 4. **Homeostasis and Regulation**: - Mechanisms of homeostasis and feedback regulation in animals: - **Negative and Positive Feedback**: Examples and physiological control mechanisms. - **Temperature Regulation**: Thermoregulation in endotherms and ectotherms. 5. **Animal Development and Life Cycles**: - Embryonic development and life cycles of animals: - **Fertilization**: Fusion of gametes and formation of zygote. - **Embryonic Development**: Cleavage, gastrulation, and organogenesis. - **Metamorphosis**: Developmental changes from larval toadult forms in insects and amphibians. - **Life Span and Aging**: Aging processes and life span variation among animals. 6. **Animal Behavior and Adaptations**: - Behavioral adaptations and their ecological significance: - **Feeding Behaviors**: Carnivores, herbivores, omnivores, and feeding strategies. - **Reproductive Behaviors**: Courtship, mating rituals, and parental care. - **Social Behaviors**: Group behaviors, communication, and cooperation. 7. **Human Impact on Animal Health and Physiology**: - Environmental factors and human activities affecting animal health and physiology: - **Pollution and Habitat Destruction**: Effects on animal populations and ecosystems. - **Climate Change**: Impact on distribution, behavior, and physiology of animals. - **Conservation and Wildlife Management**: Strategies forpreserving biodiversity and habitats. 8. **Summary and Key Concepts**:

- The chapter concludes with a summary of key concepts related totheorganization of theanimal body, reinforcing understanding of animal structure, functions, organ systems, and adaptations. Chapter 22 provides a comprehensive exploration of theorganization and physiological systems of animals, preparing students forfurther exploration into animal biology, physiology, behavior, and ecology covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 22, feel free toask! Chapter 23: theTransport Systems Chapter 23 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "The Transport Systems," typically covers themechanisms and systems involved in thetransport of materials within organisms, especially focusing on animals. Here’s an overview of what you might find in this chapter: 1. **Introduction toTransport Systems**: - Overview of theimportance of transport systems in multicellular organisms. - Comparison of transport systems in animals and plants. 2. **Transport in Single-Celled Organisms**: - Mechanisms of transport in unicellular organisms: - **Protozoans and Algae**: Movement of substances across cell membranes (diffusion, osmosis). 3. **Circulatory Systems in Invertebrates**: - **Open Circulatory Systems**: Structure and function in insects and other arthropods. - **Closed Circulatory Systems**: Structure and function in cephalopods (e.g., squids) and earthworms. 4. **Circulatory Systems in Vertebrates**: - **Fish**: Single circulatory systems in fish (e.g., bony fish). - **Amphibians**: Adaptations in amphibians (e.g., frogs) foraquatic and terrestrial life stages. - **Reptiles**: Circulatory adaptations in reptiles (e.g., crocodiles, turtles). - **Birds and Mammals**: Double circulatory systems in birds and mammals, including pulmonary and systemic circuits. 5. **Structure and Function of theHeart**: - Anatomy and physiology of thevertebrate heart: - **Chambers**: Atria and ventricles. - **Valves**: Role in preventing backflow of blood. - **Cardiac Cycle**: Phases of heart contraction (systole) and relaxation (diastole).

6. **Blood Vessels**:

- Types of blood vessels and their functions: - **Arteries**: Structure, function in carrying oxygenated blood away from theheart. - **Veins**: Structure, function in carrying deoxygenated blood back totheheart. - **Capillaries**: Structure, function in exchange of gases, nutrients, and wastes between blood and tissues. 7. **Blood Composition and Function**: - Components of blood and their roles: - **Plasma**: Fluid matrix containing water, ions, proteins, and hormones. - **Red Blood Cells**: Structure and function in oxygen transport (hemoglobin). - **White Blood Cells**: Immune function and defense against pathogens. - **Platelets**: Role in blood clotting (hemostasis). 8. **Gas Exchange Systems**: - Respiratory structures and mechanisms in animals: - **Gills**: Structure and function in aquatic animals (e.g., fish, mollusks). - **Lungs**: Structure and function in terrestrial vertebrates (e.g., reptiles, birds, mammals). 9. **Transport in Plants**: - Overview of vascular tissues (xylem and phloem) and their roles in water and nutrient transport. - Mechanisms of water movement (transpiration-cohesion-tension theory) and nutrient transport in plants. 10. **Regulation of Transport Systems**: - **Neural Control**: Role of nervous system in regulating heart rate and blood vessel diameter. - **Hormonal Control**: Role of hormones (e.g., adrenaline, antidiuretic hormone) in regulating blood pressure, fluid balance, and blood sugar levels. 11. **Health and Disorders**: - Common circulatory and respiratory disorders in humans: - **Cardiovascular Diseases**: Hypertension, coronary artery disease, stroke. - **Respiratory Diseases**: Asthma, chronic obstructive pulmonary disease (COPD). 12. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related totransport systems in animals and plants, reinforcing understanding of transport mechanisms, circulatory systems, respiratory adaptations, and regulatory processes. Chapter 23 provides a comprehensive exploration of transport systems in animals and plants, highlighting thestructural adaptations, physiological mechanisms, and regulatory controls that enable efficient transport of materials essential forlife processes. It prepares students forfurther exploration into animal physiology, plant biology, and human health covered in subsequent chapters of thetextbook.

If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 23, feel free toask! Chapter 24: theMaintenance Systems Chapter 24 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "The Maintenance Systems," typically covers thevarious systems responsible formaintaining homeostasis and supporting physiological functions in organisms. Here’s an overview of what you might find in this chapter: 1. **Introduction toMaintenance Systems**: - Overview of theimportance of homeostasis and maintenance systems in organisms. - Explanation of feedback mechanisms and their role in regulating physiological processes. 2. **The Nervous System**: - Structure and function of thenervous system: - **Central Nervous System (CNS)**: Brain and spinal cord. - **Peripheral Nervous System (PNS)**: Nerves and ganglia. - **Neurons**: Structure, function, and transmission of nerve impulses. - **Neurotransmitters**: Chemical messengers and synaptic transmission. 3. **Sensory Systems**: - Structure and function of sensory organs and receptors: - **Vision**: Structure of theeye, photoreceptors, and visual pathways. - **Hearing**: Structure of theear, mechanoreceptors, and auditory pathways. - **Taste and Smell**: Chemical senses, receptors, and sensory pathways. - **Touch and Proprioception**: Mechanoreceptors, tactile senses, and body position. 4. **Endocrine System**: - Structure and function of theendocrine system: - **Hormones**: Chemical messengers and their target organs. - **Major Endocrine Glands**: Pituitary, thyroid, adrenal glands, pancreas, gonads. - **Hormonal Regulation**: Feedback loops and hormone actions. 5. **Excretory System**: - Structure and function of theexcretory system: - **Kidneys**: Nephrons, filtration, reabsorption, and secretion. - **Urinary System**: Ureters, bladder, urethra, and urine formation. - **Regulation of Water and Electrolytes**: Osmoregulation and urine concentration. 6. **Digestive System**: - Structure and function of thedigestive system: - **Organs**: Mouth, esophagus, stomach, small intestine, large intestine, liver, pancreas. - **Digestive Processes**: Ingestion, digestion (mechanical and chemical), absorption, and elimination. - **Nutrient Metabolism**: Energy production and nutrient storage. 7. **Integumentary System**:

- Structure and function of theintegumentary system: - **Skin**: Epidermis, dermis, and hypodermis. - **Functions**: Protection, sensation, temperature regulation, and vitamin D synthesis. 8. **Musculoskeletal System**: - Structure and function of themusculoskeletal system: - **Muscles**: Types (skeletal, cardiac, smooth), structure, and contraction mechanisms. - **Skeleton**: Bones, cartilage, and joints. - **Functions**: Support, movement, and protection. 9. **Immune System**: - Structure and function of theimmune system: - **Innate Immunity**: Physical barriers, phagocytes, and inflammation. - **Adaptive Immunity**: Lymphocytes (B cells and T cells), antibodies, and immune response. - **Immune Disorders**: Autoimmune diseases, allergies, and immunodeficiency. 10. **Homeostasis and Regulation**: - Mechanisms of homeostasis and feedback regulation in physiological systems: - **Negative and Positive Feedback**: Examples and physiological control mechanisms. - **Temperature Regulation**: Thermoregulation in endotherms and ectotherms. 11. **Health and Disorders**: - Common disorders and diseases associated with maintenance systems: - **Nervous System Disorders**: Stroke, Parkinson’s disease, Alzheimer’s disease. - **Endocrine Disorders**: Diabetes mellitus, thyroid disorders. - **Digestive Disorders**: Gastrointestinal diseases (e.g., gastritis, ulcers, irritable bowel syndrome). - **Excretory Disorders**: Kidney stones, urinary tract infections. 12. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related tomaintenance systems in organisms, reinforcing understanding of physiological processes, organ systems, regulatory mechanisms, and health implications. Chapter 24 provides a comprehensive exploration of themaintenance systems in organisms, highlighting thestructural adaptations, physiological mechanisms, and regulatory controls that enable organisms tomaintain internal stability and respond toenvironmental changes. It prepares students forfurther exploration into animal physiology, human biology, and health sciences covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 24, feel free toask!

Chapter 25: Digestion and Human Nutrition

Chapter 25 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Digestion and Human Nutrition," typically covers theprocesses involved in digestion, absorption of nutrients, and therole of nutrition in human health. Here’s an overview of what you might find in this chapter: 1. **Introduction toDigestion and Nutrition**: - Overview of theimportance of digestion in obtaining nutrients forenergy and growth. - Explanation of essential nutrients and their roles in maintaining health. 2. **Digestive System Overview**: - Structure and function of thedigestive system: - **Organs**: Mouth, pharynx, esophagus, stomach, small intestine, large intestine, liver, pancreas. - **Digestive Processes**: Ingestion, propulsion, mechanical digestion, chemical digestion, absorption, and defecation. - **Accessory Organs**: Salivary glands, gallbladder. 3. **Mechanical Digestion**: - Physical breakdown of food in thedigestive tract: - **Mastication**: Chewing in themouth. - **Peristalsis**: Muscle contractions that move food through thedigestive tract. - **Segmentation**: Mixing movements in theintestines. 4. **Chemical Digestion**: - Enzymatic breakdown of macromolecules into smaller molecules: - **Proteins**: Enzymes (e.g., pepsin, trypsin) hydrolyze proteins into amino acids. - **Carbohydrates**: Enzymes (e.g., salivary amylase, pancreatic amylase) hydrolyze polysaccharides into monosaccharides. - **Lipids**: Lipases break down fats into fatty acids and glycerol. - **Nucleic Acids**: Nucleases break down nucleic acids into nucleotides. 5. **Absorption of Nutrients**: - Processes by which nutrients are absorbed into thebloodstream or lymphatic system: - **Small Intestine**: Villi and microvilli increase surface area forabsorption of nutrients (amino acids, sugars, fatty acids, vitamins, minerals). - **Large Intestine**: Absorption of water and electrolytes. 6. **Role of theLiver and Pancreas**: - **Liver**: Functions in bile production (emulsification of fats), detoxification, and storage of glycogen and vitamins. - **Pancreas**: Secretion of pancreatic enzymes (e.g., amylase, lipase, proteases) and bicarbonate into thesmall intestine. 7. **Nutrition and Nutrients**: - **Macronutrients**: Carbohydrates, proteins, fats (lipids), and their roles in energy production and cellular functions.

- **Micronutrients**: Vitamins and minerals essential formetabolism, growth, and overall health. - **Water**: Importance of hydration and fluid balance in thebody. 8. **Balanced Diet and Dietary Guidelines**: - Principles of a balanced diet: - **Energy Balance**: Calories consumed versus calories expended. - **Dietary Guidelines**: Recommendations fornutrient intake (e.g., Dietary Reference Intakes, Daily Values). - **Food Pyramid and MyPlate**: Guidelines forhealthy eating patterns. 9. **Nutritional Disorders**: - Common nutritional deficiencies and disorders: - **Malnutrition**: Undernutrition (e.g., protein-energy malnutrition) and overnutrition (e.g., obesity). - **Specific Deficiencies**: Iron deficiency anemia, vitamin deficiencies (e.g., vitamin D deficiency), and their health impacts. 10. **Digestive Disorders**: - Common disorders affecting thedigestive system: - **Gastroesophageal Reflux Disease (GERD)**: Acid reflux and heartburn. - **Peptic Ulcers**: Lesions in thestomach or duodenum. - **Inflammatory Bowel Diseases (IBD)**: Crohn's disease and ulcerative colitis. 11. **Digestive Health and Lifestyle**: - Factors influencing digestive health: - **Dietary Habits**: Effects of fiber, fats, and sugars on digestive processes. - **Hydration**: Importance of water intake fordigestion and overall health. - **Physical Activity**: Role in digestion and metabolism. 12. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related todigestion and human nutrition, reinforcing understanding of digestive processes, nutrient absorption, dietary requirements, and health implications. Chapter 25 provides a comprehensive exploration of digestion, nutrient absorption, and human nutrition, highlighting theprocesses and principles essential formaintaining health and well- being. It prepares students forfurther exploration into human physiology, dietetics, and health sciences covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 25, feel free toask! Chapter 26: Defenses Against Disease

Chapter 26 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Defenses Against Disease," typically covers theimmune system, its components, functions, and mechanisms of defense against pathogens. Here’s an overview of what you might find in this chapter: 1. **Introduction totheImmune System**: - Overview of theimmune system as a defense mechanism against pathogens and foreign invaders. - Importance of immunity in maintaining health and preventing diseases. 2. **Innate Immunity**: - **Physical Barriers**: Skin, mucous membranes, and secretions (e.g., tears, saliva) that prevent pathogen entry. - **Cellular Defenses**: Phagocytes (e.g., neutrophils, macrophages) that engulf and digest pathogens. - **Inflammatory Response**: Localized response totissue damage or infection, characterized by redness, swelling, heat, and pain. - **Complement System**: Proteins that enhance immune responses by promoting phagocytosis and inflammation. 3. **Adaptive Immunity**: - **Antigens and Antibodies**: Recognition of specific antigens by antibodies produced by B cells. - **Cell-Mediated Immunity**: T cells (e.g., cytotoxic T cells) that directly attack infected or abnormal cells. - **Humoral Immunity**: B cells that produce antibodies toneutralize pathogens and toxins in body fluids. - **Memory Cells**: Long-lived lymphocytes (memory B cells and memory T cells) that provide long-term immunity against previously encountered pathogens. 4. **Immune Response**: - **Primary and Secondary Responses**: Initial immune response toa new antigen (primary response) and enhanced response upon re-exposure (secondary response). - **Antigen Presentation**: Process by which antigen-presenting cells (e.g., dendritic cells) display antigens toT cells toinitiate immune responses. 5. **Vaccination and Immunization**: - **Vaccines**: Mechanism of action, types (live attenuated, inactivated, subunit, conjugate vaccines), and benefits in preventing infectious diseases. - **Herd Immunity**: Protection of a population against infectious diseases through high vaccination coverage. 6. **Autoimmunity and Allergies**: - **Autoimmune Diseases**: Conditions where theimmune system mistakenly attacks thebody’s own tissues (e.g., rheumatoid arthritis, multiple sclerosis).

- **Allergic Reactions**: Hypersensitivity reactions (e.g., asthma, hay fever) toharmless substances (allergens) due toimmune system overreaction. 7. **Immune Disorders**: - **Immunodeficiency Disorders**: Conditions where theimmune system is weakened or impaired (e.g., HIV/AIDS, primary immunodeficiency disorders). - **Cancer and Immune Evasion**: Strategies by which cancer cells evade immune detection and destruction. 8. **Immune System and Health**: - Factors influencing immune function and health: - **Nutrition**: Effects of diet and nutrients (e.g., vitamins, minerals) on immune responses. - **Lifestyle**: Impact of stress, sleep, exercise, and hygiene on immune system function. 9. **Emerging Infectious Diseases and Global Health**: - **Pandemics and Epidemics**: Spread and control of infectious diseases on a global scale (e.g., COVID-19, influenza). - **Public Health Measures**: Strategies fordisease prevention, surveillance, and outbreak response. 10. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related todefenses against disease, reinforcing understanding of immune system components, immune responses, diseases, and health implications. Chapter 26 provides a comprehensive exploration of theimmune system and defenses against disease, highlighting themechanisms and principles essential forunderstanding how organisms protect themselves against pathogens. It prepares students forfurther exploration into immunology, microbiology, epidemiology, and public health covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 26, feel free toask!

Chapter 27 Chapter 27: theControl Systems Chapter 27 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "The Control Systems," typically covers thevarious regulatory mechanisms that organisms use tocoordinate and control their physiological processes. Here’s an overview of what you might find in this chapter: 1. **Introduction toControl Systems**:

- Overview of regulatory mechanisms in organisms. - Importance of coordination and control formaintaining homeostasis.

2. **Nervous System**: - Structure and function of thenervous system: - **Central Nervous System (CNS)**: Brain and spinal cord. - **Peripheral Nervous System (PNS)**: Nerves and ganglia. - **Neurons**: Structure, function, and transmission of nerve impulses. - **Neurotransmitters**: Chemical messengers and synaptic transmission. 3. **Endocrine System**: - Structure and function of theendocrine system: - **Hormones**: Chemical messengers produced by endocrine glands. - **Major Endocrine Glands**: Pituitary, thyroid, adrenal glands, pancreas, gonads. - **Hormonal Regulation**: Feedback loops and hormone actions. 4. **Integration of Nervous and Endocrine Systems**: - Coordination and communication between thenervous and endocrine systems in regulating physiological processes (e.g., stress response, metabolism, growth). 5. **Homeostasis and Feedback Mechanisms**: - Mechanisms of homeostasis and feedback regulation: - **Negative Feedback**: Mechanism by which thebody maintains stability by counteracting deviations from normal levels. - **Positive Feedback**: Amplification of a physiological response (less common in maintaining homeostasis). 6. **Sensory Receptors and Signal Transduction**: - Types of sensory receptors and their roles in detecting stimuli (e.g., light, sound, touch, chemicals). - Signal transduction pathways: Conversion of sensory stimuli into electrical signals in neurons. 7. **Regulation of Physiological Processes**: - Examples of control and coordination in physiological systems: - **Temperature Regulation**: Thermoregulation mechanisms in endotherms and ectotherms. - **Water and Electrolyte Balance**: Osmoregulation and regulation of blood pressure. - **Metabolism**: Regulation of energy balance and nutrient utilization. 8. **Development and Aging**: - Control systems involved in development, growth, and aging: - **Developmental Signals**: Hormonal and genetic signals regulating embryonic development. - **Aging and Senescence**: Physiological changes and decline in regulatory mechanisms with age. 9. **Health and Disorders**:

- Disorders related tocontrol systems: - **Neurological Disorders**: Alzheimer’s disease, Parkinson’s disease, epilepsy. - **Endocrine Disorders**: Diabetes mellitus, thyroid disorders. - **Disruptions in Homeostasis**: Effects of environmental factors, lifestyle, and genetic predisposition. 10. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related tocontrol systems in biology, reinforcing understanding of regulatory mechanisms, integration of nervous and endocrine systems, and health implications. Chapter 27 provides a comprehensive exploration of control systems in organisms, highlighting theregulatory mechanisms that coordinate and maintain physiological processes necessary forsurvival and adaptation. It prepares students forfurther exploration into neurobiology, endocrinology, physiology, and related fields covered in subsequent chapters of thetextbook. If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 27, feel free toask! Chapter 28: Sensory Input and Motor Output Chapter 28 of "Essentials of Biology" by Sylvia Mader and Michael Windelspecht, titled "Sensory Input and Motor Output," typically covers themechanisms involved in sensory perception and motor responses in organisms. Here’s an overview of what you might find in this chapter: 1. **Introduction toSensory Input and Motor Output**: - Overview of sensory systems and motor responses in organisms. - Importance of sensory perception and motor control forsurvival and adaptation. 2. **Sensory Systems**: - Types of sensory receptors and their roles in detecting stimuli: - **Vision**: Structure of theeye, photoreceptors (rods and cones), and visual pathways. - **Hearing**: Structure of theear, mechanoreceptors (hair cells), and auditory pathways. - **Taste and Smell**: Chemoreceptors and sensory pathways fordetecting chemicals. - **Touch and Proprioception**: Mechanoreceptors and sensory pathways fordetecting pressure, temperature, and body position. 3. **Signal Transduction in Sensory Systems**: - Mechanisms by which sensory stimuli are detected and converted into electrical signals: - **Receptor Potential**: Generation of electrical signals in sensory receptors (e.g., depolarization). - **Transmission of Signals**: Nerve impulses (action potentials) and synaptic transmission tothecentral nervous system.

4. **Integration and Processing of Sensory Information**: - Processing of sensory input in thecentral nervous system (brain and spinal cord):

- **Sensory Pathways**: Transmission and integration of sensory information in thebrain. - **Perception**: Interpretation of sensory stimuli toform perceptions of theexternal environment. 5. **Motor Systems**: - Types of motor neurons and their roles in initiating and coordinating movement: - **Somatic Motor System**: Control of voluntary movements (e.g., skeletal muscles). - **Autonomic Nervous System**: Control of involuntary movements (e.g., cardiac muscle, smooth muscle). 6. **Control of Movement**: - Mechanisms of motor control and coordination: - **Motor Cortex**: Planning and initiation of voluntary movements. - **Basal Ganglia and Cerebellum**: Coordination and refinement of motor movements. - **Spinal Cord Reflexes**: Reflex arcs and automatic responses tostimuli. 7. **Neuromuscular Junction**: - Synaptic connection between motor neurons and muscle fibers: - **Acetylcholine Release**: Neurotransmitter released at neuromuscular junctions. - **Muscle Contraction**: Mechanism of sliding filament theory and cross-bridge cycling. 8. **Feedback Mechanisms in Motor Control**: - Role of sensory feedback (proprioception, vision) in regulating and adjusting movements: - **Feedback Loops**: Reflex arcs and adjustments in response tosensory input during movement. 9. **Health and Disorders**: - Disorders related tosensory input and motor output: - **Neurological Disorders**: Stroke, spinal cord injury, motor neuron diseases (e.g., ALS). - **Sensory Impairments**: Vision disorders (e.g., cataracts, glaucoma), hearing loss, sensory processing disorders. - **Motor Disorders**: Parkinson’s disease, muscular dystrophy, motor coordination disorders. 10. **Summary and Key Concepts**: - The chapter concludes with a summary of key concepts related tosensory input and motor output, reinforcing understanding of sensory systems, motor control mechanisms, and their roles in organismal function. Chapter 28 provides a comprehensive exploration of sensory perception and motor responses in organisms, highlighting themechanisms and principles essential forunderstanding how organisms interact with their environment and control their movements. It prepares students forfurther exploration into neuroscience, physiology, psychology, and related fields covered in subsequent chapters of thetextbook.

If you have specific questions about any of these topics or would like more detailed information on a particular aspect of Chapter 28, feel free toask!

Chapter 29 Chapter 29 likely covers fundamental aspects of reproduction, development, and aging in organisms. Here’s a general outline of what such a chapter might include: 1. **Introduction toReproduction**: - Definitions of reproduction and its significance in biology. - Types of reproduction: sexual and asexual. 2. **Sexual Reproduction**: - Processes involved: gametogenesis (formation of gametes), fertilization. - Mechanisms ensuring genetic diversity: recombination, independent assortment. 3. **Asexual Reproduction**: - Types of asexual reproduction: budding, fission, regeneration. - Advantages and disadvantages compared tosexual reproduction. 4. **Developmental Biology**: - Overview of embryonic development. - Major stages: fertilization, cleavage, gastrulation, organogenesis. - Signaling pathways and genetic regulation during development. 5. **Aging and Senescence**: - Definitions of aging and senescence. - Theories of aging: programmed aging vs. damage accumulation. - Cellular and molecular mechanisms underlying aging: telomere shortening, oxidative stress, mitochondrial dysfunction. 6. **Reproductive Strategies**: - Strategies forreproductive success: r vs. K selection. - Life history traits and their adaptations. 7. **Human Reproduction** (if applicable): - Reproductive anatomy and physiology. - Menstrual cycle, ovulation, spermatogenesis.

- Fertilization, pregnancy, and childbirth. 8. **Environmental Influences**: - Impact of environmental factors on reproduction and development.

- Evolutionary perspectives on reproductive strategies in changing environments. 9. **Social and Ethical Considerations**: - Ethical issues related toreproductive technologies. - Social impacts of aging populations and implications forhealthcare and society. 10. **Current Research and Future Directions**: - Advances in reproductive biology and aging research. - Emerging technologies and their implications. Each section typically covers both thetheoretical underpinnings and practical applications or implications of thediscussed topics. It’s a broad and interdisciplinary field that integrates genetics, physiology, ecology, and evolution tounderstand how organisms reproduce, develop, and age over their lifetimes. Chapter 30 Chapter 30, "Ecology of Populations," would delve into thedynamics, interactions, and characteristics of populations within ecosystems. Here’s an outline of what such a chapter might cover: 1. **Population Dynamics**: - Definition of a population and its characteristics. - Population size, density, distribution (dispersion patterns), and age structure. - Factors affecting population growth: birth rates, death rates, immigration, emigration. 2. **Population Growth Models**: - Exponential growth model: idealized conditions and its implications. - Logistic growth model: carrying capacity and density-dependent regulation. - Factors influencing carrying capacity. 3. **Life History Strategies**: - r-selection vs. K-selection: reproductive strategies and survivorship curves. - Trade-offs in life history traits: reproduction, growth, and survival. 4. **Population Interactions**: - Competition: types (intraspecific vs. interspecific), competitive exclusion principle, resource partitioning. - Predation: predator-prey interactions, coevolution, adaptations. - Mutualism, commensalism, and parasitism: ecological relationships and examples. 5. **Population Regulation**: - Density-dependent vs. density-independent factors. - Examples of density-dependent regulation: disease, predation, competition. - Allee effects and their implications forsmall populations.

6. **Population Dynamics in Changing Environments**:

- Responses toenvironmental changes: adaptations, migration, extinction. - Succession: primary and secondary succession, role of pioneer species. 7. **Metapopulations**: - Definition and characteristics of metapopulations. - Dynamics of occupied and unoccupied patches. - Conservation implications: habitat fragmentation and connectivity. 8. **Human Impacts on Populations**: - Overexploitation: hunting, fishing, harvesting. - Habitat destruction and fragmentation. - Invasive species and their effects on native populations. 9. **Population Monitoring and Management**: - Methods forestimating population size and trends. - Conservation strategies: captive breeding, habitat restoration, protected areas. 10. **Emerging Topics and Future Directions**: - Population genetics and genomics. - Effects of climate change on population dynamics. - Integrating ecological and evolutionary perspectives in population studies. This chapter would provide a comprehensive overview of how populations of organisms interact with their environment and each other, and how these interactions shape ecological communities and ecosystems. It would also highlight theimportance of understanding population dynamics forconservation and management efforts in a rapidly changing world.

Chapter 31 Chapter 31, "Communities and Ecosystems," focuses on understanding theinteractions between different species within ecological communities and their broader impact on ecosystems. Here’s an outline of what such a chapter might cover: 1. **Introduction toCommunities and Ecosystems**: - Definitions of community and ecosystem. - Levels of organization: individual, population, community, ecosystem. 2. **Community Structure**: - Species diversity: species richness, evenness, and diversity indices. - Trophic structure: producers, consumers (herbivores, carnivores, omnivores), decomposers. - Food chains and food webs: energy flow and trophic levels.

3. **Species Interactions**: - Competition: competitive exclusion principle, niche differentiation. - Predation: predator-prey dynamics, coevolution. - Mutualism: ecological interactions benefiting both species.

- Commensalism and parasitism: types of symbiosis and their ecological roles. 4. **Community Dynamics**: - Succession: primary and secondary succession, pioneer species, climax communities. - Disturbance ecology: role of disturbances in shaping community structure and diversity. - Stability and resilience: community responses toenvironmental changes and disturbances. 5. **Ecosystem Structure and Function**: - Energy flow: primary productivity, energy transfer between trophic levels. - Nutrient cycling: carbon, nitrogen, phosphorus cycles. - Biogeochemical cycles: global-scale cycling of elements through ecosystems. 6. **Ecosystem Services**: - Provisioning, regulating, supporting, and cultural services provided by ecosystems. - Importance of biodiversity forecosystem functioning and services. 7. **Human Impacts on Communities and Ecosystems**: - Habitat destruction and fragmentation. - Invasive species and their effects on native communities. - Pollution and nutrient enrichment (eutrophication). 8. **Conservation and Management of Ecosystems**: - Conservation biology principles: biodiversity hotspots, ecosystem restoration. - Sustainable management practices: ecosystem-based management, sustainable agriculture. 9. **Global Change and Ecosystem Responses**: - Climate change impacts on ecosystems: shifts in species distributions, phenology changes. - Ocean acidification and its effects on marine ecosystems. - Predicting and mitigating theeffects of global change on ecosystems. 10. **Emerging Topics and Future Directions**: - Integrating ecological and evolutionary perspectives in community ecology. - Advances in ecological modeling and remote sensing. - Novel ecosystems and their implications forbiodiversity conservation. This chapter would provide a comprehensive overview of how communities of organisms interact and function within ecosystems, and how these interactions are influenced by environmental factors and human activities. Understanding these dynamics is crucial foreffective conservation and management of natural resources and biodiversity. Chapter 32 Chapter 32, "Human Impact on theBiosphere," would explore theprofound effects that human activities have on Earth's ecosystems, biodiversity, and natural resources. Here’s an outline of what such a chapter might cover:

1. **Introduction toHuman Impact on theBiosphere**:

- Overview of thebiosphere and its interconnected systems. - Human population growth and its implications forresource consumption. 2. **Land Use Change**: - Deforestation: causes, consequences forbiodiversity and climate. - Urbanization: impacts on habitats and ecosystems. 3. **Pollution**: - Types of pollution: air, water, soil, and noise pollution. - Sources and effects of pollution on ecosystems and human health. - Case studies of major pollution incidents (e.g., oil spills, industrial accidents). 4. **Climate Change**: - Causes and mechanisms of climate change. - Impacts on ecosystems: shifts in species distributions, phenology changes. - Global warming potential and greenhouse gas emissions. 5. **Loss of Biodiversity**: - Extinction crisis: rates of species extinction and endangerment. - Habitat destruction and fragmentation. - Invasive species and their ecological impacts. 6. **Overexploitation of Resources**: - Fisheries depletion: overfishing and bycatch. - Mining and extraction: impacts on ecosystems and local communities. - Agriculture and water use: sustainable practices vs. depletion of resources. 7. **Eutrophication and Water Quality**: - Nutrient pollution in aquatic ecosystems. - Harmful algal blooms and dead zones. - Management strategies fornutrient reduction. 8. **Conservation Efforts**: - International agreements and conventions (e.g., Convention on Biological Diversity, Paris Agreement). - Protected areas: national parks, marine reserves, and their effectiveness. - Restoration ecology: efforts torestore degraded ecosystems. 9. **Sustainable Development**: - Principles of sustainable development: balancing economic growth with environmental protection. - Sustainable agriculture and forestry practices. - Renewable energy sources and their potential tomitigate environmental impacts. 10. **Ethical and Social Considerations**: - Environmental justice and equity.

- Indigenous knowledge and conservation practices. - Public awareness and education forsustainable living. 11. **Future Challenges and Solutions**: - Emerging technologies forenvironmental monitoring and mitigation. - Integrating resilience and adaptation strategies in policy-making. - Global cooperation and governance forsustainable development goals. This chapter would highlight theinterconnectedness of human activities with thebiosphere, emphasizing theurgency of addressing environmental challenges through informed policies, technological innovations, and societal changes toachieve a sustainable future forboth humans and ecosystems.

Metamorphosis Article Talk Read Edit View history Tools Appearance hide Text Small Standard Large Width

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Standard Wide From Wikipedia, thefree encyclopedia This article is about thebiological process. fortheFranz Kafka novella, see theMetamorphosis. forother uses, see Metamorphosis (disambiguation). A dragonfly in its final moult, undergoing metamorphosis, it begins transforming from its nymph form toan adult Metamorphosis is a biological process by which an animal physically develops including birth transformation or hatching, involving a conspicuous and relatively abrupt change in theanimal's body structure through cell growth and differentiation.[1] Some insects, jellyfish, fish, amphibians, mollusks, crustaceans, cnidarians, echinoderms, and tunicates undergo metamorphosis, which is often accompanied by a change of nutrition source or behavior.[2] Animals can be divided into species that undergo complete metamorphosis ("holometaboly"), incomplete metamorphosis ("hemimetaboly"), or no metamorphosis ("ametaboly").[3] Generally organisms with a larval stage undergo metamorphosis, and during metamorphosis theorganism loses larval characteristics. [4] Etymology The word metamorphosis derives from Ancient Greek μεταμόρφωσις, "transformation, transforming",[5] from μετα- (meta-), "after" and μορφή (morphe), "form".[6] Hormonal control In insects, growth and metamorphosis are controlled by hormones synthesized by endocrine glands near thefront of thebody (anterior). Neurosecretory cells in an insect's brain secrete a hormone, theprothoracicotropic hormone (PTTH) that activates prothoracic glands, which secrete a second hormone, usually ecdysone (an ecdysteroid), that induces ecdysis (shedding of theexoskeleton).[7] PTTH also stimulates thecorpora allata, a retrocerebral organ, toproduce juvenile hormone, which prevents thedevelopment of adult characteristics during ecdysis. In holometabolous insects, molts between larval instars have a high level of juvenile hormone, themoult

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tothepupal stage has a low level of juvenile hormone, and thefinal, or imaginal, molt has no juvenile hormone present at all.[8] Experiments on firebugs have shown how juvenile hormone can affect thenumber of nymph instar stages in hemimetabolous insects.[9][10] In chordates, metamorphosis is iodothyronine-induced and an ancestral feature of all chordates.[11] Insects Incomplete metamorphosis in thegrasshopper with different instar nymphs. thelargest specimen is adult. All three categories of metamorphosis can be found in thediversity of insects, including no metamorphosis ("ametaboly"), incomplete or partial metamorphosis ("hemimetaboly"), and complete metamorphosis ("holometaboly"). While ametabolous insects show very little difference between larval and adult forms (also known as "direct development"), both hemimetabolous and holometabolous insects have significant morphological and behavioral differences between larval and adult forms, themost significant being theinclusion, in holometabolous organisms, of a pupal or resting stage between thelarval and adult forms. Development and terminology Two types of metamorphosis are shown. In a complete (holometabolous) metamorphosis theinsect passes through four distinct phases, which produce an adult that does not resemble thelarva. In an incomplete (hemimetabolous) metamorphosis an insect does not go through a full transformation, but instead transitions from a nymph toan adult by molting its exoskeleton as it grows. In hemimetabolous insects, immature stages are called nymphs. Development proceeds in repeated stages of growth and ecdysis (moulting); these stages are called instars. thejuvenile forms closely resemble adults, but are smaller and lack adult features such as wings and genitalia. thesize and morphological differences between nymphs in different instars are small, often just differences in body proportions and thenumber of segments; in later instars, external wing buds form. theperiod from one molt tothenext is called a stadium.[12]

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In holometabolous insects, immature stages are called larvae and differ markedly from adults. Insects which undergo holometabolism pass through a larval stage, then enter an inactive state called pupa (called a "chrysalis" in butterfly species), and finally emerge as adults.[13] Evolution The earliest insect forms showed direct development (ametabolism), and theevolution of metamorphosis in insects is thought tohave fuelled their dramatic radiation (1,2). Some early ametabolous "true insects" are still present today, such as bristletails and silverfish. Hemimetabolous insects include cockroaches, grasshoppers, dragonflies, and true bugs. Phylogenetically, all insects in thePterygota undergo a marked change in form, texture and physical appearance from immature stage toadult. These insects either have hemimetabolous development, and undergo an incomplete or partial metamorphosis, or holometabolous development, which undergo a complete metamorphosis, including a pupal or resting stage between thelarval and adult forms.[14] A number of hypotheses have been proposed toexplain theevolution of holometaboly from hemimetaboly, mostly centering on whether or not theintermediate stages of hemimetabolous forms are homologous in origin tothepupal stage of holometabolous forms. Temperature-dependent metamorphosis According toa 2009 study, temperature plays an important role in insect development as individual species are found tohave specific thermal windows that allow them toprogress through their developmental stages. These windows are not significantly affected by ecological traits, rather, thewindows are phylogenetically adapted totheecological circumstances insects are living in.[15] Recent research According toresearch from 2008, adult Manduca sexta is able toretain behavior learned as a caterpillar.[16] Another caterpillar, theornate moth caterpillar, is able tocarry toxins that it acquires from its diet through metamorphosis and into adulthood, where thetoxins still serve forprotection against predators.[17]

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Many observations published in 2002, and supported in 2013 indicate that programmed cell death plays a considerable role during physiological processes of multicellular organisms, particularly during embryogenesis, and metamorphosis.[18][19] Additional research in 2019 found that both autophagy and apoptosis, thetwo ways programmed cell death occur, are processes undergone during insect metamorphosis. [20] Below is thesequence of steps in themetamorphosis of thebutterfly (illustrated): Metamorphosis of butterfly (PSF) 1 – thelarva of a butterfly 2 – thepupa is now spewing thethread toform chrysalis 3 – thechrysalis is fully formed 4 – Adult butterfly coming out of thechrysalis Sequence illustrating complete metamorphosis in thecabbage white butterfly, Pieris rapae larva larva pupa pupa pupa ready tohatch pupa ready tohatch adult adult Chordata Amphioxus

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In cephalochordata, metamorphosis is iodothyronine-induced and it could be an ancestral feature of all chordates.[11] Fish Some fish, both bony fish (Osteichthyes) and jawless fish (Agnatha), undergo metamorphosis. Fish metamorphosis is typically under strong control by thethyroid hormone.[21] Examples among thenon-bony fish include thelamprey. Among thebony fish, mechanisms are varied. The salmon is diadromous, meaning that it changes from a freshwater toa saltwater lifestyle. Many species of flatfish begin their life bilaterally symmetrical, with an eye on either side of thebody; but one eye moves tojoin theother side of thefish – which becomes theupper side – in theadult form. The European eel has a number of metamorphoses, from thelarval stage totheleptocephalus stage, then a quick metamorphosis toglass eel at theedge of thecontinental shelf (eight days fortheJapanese eel), two months at theborder of fresh and salt water where theglass eel undergoes a quick metamorphosis into elver, then a long stage of growth followed by a more gradual metamorphosis tothemigrating phase. In thepre-adult freshwater stage, theeel also has phenotypic plasticity because fish-eating eels develop very wide mandibles, making thehead look blunt. Leptocephali are common, occurring in all Elopomorpha (tarpon- and eel-like fish). Most other bony fish undergo metamorphosis initially from egg toimmotile larvae known as sac fry (fry with a yolk sac), then tomotile larvae (often known as fingerlings due tothem roughly reaching thelength of a human finger) that have toforage forthemselves after theyolk sac resorbs, and then tothejuvenile stage where thefish progressively start toresemble adult morphology and behaviors until finally reaching sexual maturity.[22][23] Amphibians

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Just before metamorphosis, only 24 hours are needed toreach thestage in thenext picture. Almost functional common frog with some remains of thegill sac and a not fully developed jaw In typical amphibian development, eggs are laid in water and larvae are adapted toan aquatic lifestyle. Frogs, toads, and newts all hatch from theeggs as larvae with external gills but it will take some time fortheamphibians tointeract outside with pulmonary respiration. Afterwards, newt larvae start a predatory lifestyle, while tadpoles mostly scrape food off surfaces with their horny tooth ridges. Metamorphosis in amphibians is regulated by thyroxin concentration in theblood, which stimulates metamorphosis, and prolactin, which counteracts its effect. Specific events are dependent on threshold values fordifferent tissues. Because most embryonic development is outside theparental body, development is subject tomany adaptations due tospecific ecological circumstances. forthis reason tadpoles can have horny ridges forteeth, whiskers, and fins. They also make use of thelateral line organ. After metamorphosis, these organs become redundant and will be resorbed by controlled cell death, called apoptosis. theamount of adaptation tospecific ecological circumstances is remarkable, with many discoveries still being made. Frogs and toads With frogs and toads, theexternal gills of thenewly hatched tadpole are covered with a gill sac after a few days, and lungs are quickly formed. Front legs are formed under thegill sac, and hindlegs are visible a few days later. Following that there is usually a longer stage during which thetadpole lives off a vegetarian diet. Tadpoles use a relatively long, spiral‐shaped gut todigest that diet. Recent studies suggest tadpoles do not have a balanced homeostatic feedback control system until thebeginning stages of metamorphosis. At this point, their long gut shortens and begins favoring thediet of insects.[24] Rapid changes in thebody can then be observed as thelifestyle of thefrog changes completely. thespiral‐shaped mouth with horny tooth ridges is resorbed together with thespiral gut. theanimal develops a big jaw, and its gills disappear along with its gill sac. Eyes and legs grow quickly, a tongue is

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formed, and all this is accompanied by associated changes in theneural networks (development of stereoscopic vision, loss of thelateral line system, etc.) All this can happen in about a day, so it is truly a metamorphosis. It is not until a few days later that thetail is reabsorbed, due tothehigher thyroxin concentrations required fortail resorption. Salamanders Salamander development is highly diverse; some species go through a dramatic reorganization when transitioning from aquatic larvae toterrestrial adults, while others, such as theaxolotl, display pedomorphosis and never develop into terrestrial adults. Within thegenus Ambystoma, species have evolved tobe pedomorphic several times, and pedomorphosis and complete development can both occur in some species.[21] Newts The large external gills of thecrested newt In newts, metamorphosis occurs due tothechange in habitat, not a change in diet, because newt larvae already feed as predators and continue doing so as adults. Newts' gills are never covered by a gill sac and will be resorbed only just before theanimal leaves thewater. Adults can move faster on land than in water.[25] Newts often have an aquatic phase in spring and summer, and a land phase in winter. foradaptation toa water phase, prolactin is therequired hormone, and foradaptation totheland phase, thyroxin. External gills do not return in subsequent aquatic phases because these are completely absorbed upon leaving thewater forthefirst time. Caecilians Basal caecilians such as Ichthyophis go through a metamorphosis in which aquatic larva transition into fossorial adults, which involves a loss of thelateral line.[26] More recently diverged caecilians (the Teresomata) do not undergo an ontogenetic niche shift of this sort and are in general fossorial throughout their lives. Thus, most caecilians do not undergo an anuran-like metamorphosis.[27] See also Developmental biology – Study of how organisms develop and grow

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Direct development – Growth toadulthood without metamorphosis Gosner stage – System of describing stages of development in anurans Hypermetamorphosis – High variability forms of complete metamorphosis Morphogenesis – Biological process that causes an organism todevelop its shape References "metamorphosis | biology | Britannica". www.britannica.com. Retrieved 2022-04-01. "What animals undergo incomplete metamorphosis? – Easierwithpractice.com". easierwithpractice.com. Retrieved 2022-04-01. Truman, James W. (2019-12-02). "The Evolution of Insect Metamorphosis". Current Biology. 29 (23): R1252–R1268. Bibcode:2019CBio...29R1252T. doi:10.1016/j.cub.2019.10.009. ISSN 0960-9822. PMID 31794762. S2CID 208541817. Hadfield, Michael G. (1 December 2000). "Why and how marine-invertebrate larvae metamorphose so fast". Seminars in Cell & Developmental Biology. 11 (6): 437–443. doi:10.1006/scdb.2000.0197. ISSN 1084-9521. PMID 11145872. Retrieved 7 March 2022. Liddell, Henry George; Scott, Robert (1940). "Metamorphosis". A Greek-English Lexicon. Oxford: Clarendon Press. Retrieved 2012-08-26 – via perseus.tufts.edu. "Online Etymology Dictionary". Etymonline.com. Retrieved 2012-08-26. Davies, 1998. Chapter 3. Gullan, P.J. & Cranston, P.S. 6.3 Process and Control of Moulting in theInsects: An Outline of Entomology. Blackwell Publishing, 2005. pp. 153-156. Slama; Williams (1965). "Juvenile hormone activity forthebug Pyrrhocoris apterus". Proceedings of theNational Academy of Sciences. 54 (2): 411–414. Bibcode:1965PNAS...54..411S. doi:10.1073/pnas.54.2.411. PMC 219680. PMID 5217430. Singh, Amit; Konopova, Barbora; Smykal, Vlastimil; Jindra, Marek (2011). "Common and Distinct Roles of Juvenile Hormone Signaling Genes in Metamorphosis of Holometabolous and Hemimetabolous Insects". PLOS ONE. 6 (12): e28728. Bibcode:2011PLoSO...628728K. doi:10.1371/journal.pone.0028728. ISSN 1932-6203. PMC 3234286. PMID 22174880. Denser, Robert J. (2008). "Chordate Metamorphosis: Ancient Control by Iodothyronines" (PDF). Current Biology. 18 (13): R567–9.

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Bibcode:2008CBio...18.R567D. doi:10.1016/j.cub.2008.05.024. PMID 18606129. S2CID 18587560. Schaefer, C.W. (March 1971). "Instar, Stadium, and Stage: A New Look at Old Questions". Bulletin of theEntomological Society of America. 17 (1): 17. doi:10.1093/besa/17.1.17c. Lowe, Tristan; Garwood, Russell P.; Simonsen, Thomas; Bradley, Robert S.; Withers, Philip J. (July 6, 2013). "Metamorphosis revealed: Time-lapse threedimensional imaging inside a living chrysalis". Journal of theRoyal Society Interface. 10 (84). 20130304. doi:10.1098/rsif.2013.0304. PMC 3673169. PMID 23676900. Gullan, P.J. & Cranston, P.S. 6.2 Life History Patterns and Phases in theInsects: An Outline of Entomology. pp. 143–153. 2005 by Blackwell Publishing Dixon, A. F. G., A. Honěk, P. Keil, M. A. A. Kotela, A. L. Šizling, and V. Jarošík. 2009. Relationship between theminimum and maximum temperature thresholds fordevelopment in insects. Funct. Ecol. 23: 257–264. Douglas J. Blackiston, Elena Silva Casey & Martha R. Weiss (2008). "Retention of memory through metamorphosis: can a moth remember what it learned as a caterpillar?". PLoS ONE. 3 (3): e1736. Bibcode:2008PLoSO...3.1736B. doi:10.1371/journal.pone.0001736. PMC 2248710. PMID 18320055. Conner, W.E. (2009). Tiger Moths and Woolly Bears—behaviour, ecology, and evolution of theArctiidae. New York: Oxford University Press. pp. 1–10. Lee, Gyunghee; Sehgal, Ritika; Wang, Zixing; Nair, Sudershana; Kikuno, Keiko; Chen, Chun-Hong; Hay, Bruce; Park, Jae H. (2013-03-15). "Essential role of grim-led programmed cell death fortheestablishment of corazonin-producing peptidergic nervous system during embryogenesis and metamorphosis in Drosophila melanogaster". Biology Open. 2 (3): 283–294. doi:10.1242/bio.20133384. ISSN 2046-6390. PMC 3603410. PMID 23519152. Zakeri, Zahra; Lockshin, Richard A. (2002-07-01). "Cell death during development". Journal of Immunological Methods. 265 (1–2): 3–20. doi:10.1016/s0022-1759(02)00067-4. ISSN 0022-1759. PMID 12072175. Rolff, Jens; Johnston, Paul R.; Reynolds, Stuart (2019-08-26). "Complete metamorphosis of insects". Philosophical Transactions of theRoyal Society B: Biological Sciences. 374 (1783). theRoyal Society: 20190063. doi:10.1098/rstb.2019.0063. ISSN 0962-8436. PMC 6711294. PMID 31438816. Laudet, Vincent (September 27, 2011). "The Origins and Evolution of Vertebrate Metamorphosis". Current Biology. 21 (18): R726–R737. Bibcode:2011CBio...21.R726L. doi:10.1016/j.cub.2011.07.030. PMID 21959163. Mader, Sylvia, Biology 9th ed. Ch. 31

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Peter B. Moyle and Joseph J. Cech Jr, Fishes: an introduction toichthyology 5th ed. 9.3: "Development" pp 148ff Bender, Melissa (March 28, 2018). "To eat or not toeat: ontogeny of hypothalamic feeding controls and a role forleptin in modulating life-history transition in amphibian tadpoles". theRoyal Society Publishing. 285 (1875). doi:10.1098/rspb.2017.2784. PMC 5897637. PMID 29593109. S2CID 4853293. Wilson, Robbie (November–December 2005). "Consequences of Metamorphosis fortheLocomotor Performance and Thermal Physiology of theNewt Triturus cristatus". Physiological and Biochemical Zoology. 78 (6): 967– 975. doi:10.1086/432923. JSTOR 10.1086/432923. PMID 16228936. S2CID 34285867. Retrieved 28 December 2020. Dunker, Nicole; Wake, Marvalee H.; Olson, Wendy M. (January 2000). "Embryonic and Larval Development in theCaecilian Ichthyophis kohtaoensis (Amphibia, Gymnophiona): A Staging Table". Journal of Morphology. 243 (1): 3–34. doi:10.1002/(sici)1097-4687(200001)243:1<3::aid-jmor2>3.3.co;2-4. PMID 10629095. San Mauro, D.; Gower, D. J.; Oommen, O. V.; Wilkinson, M.; Zardoya, R. (November 2004). "Phylogeny of caecilian amphibians (Gymnophiona) based on complete mitochondrial genomes and nuclear RAG1". Molecular Phylogenetics and Evolution. 33 (2): 413–427. Bibcode:2004MolPE..33..413S. doi:10.1016/j.ympev.2004.05.014. PMID 15336675. Bibliography Davies, R.G. (1998). Outlines of Entomology. Chapman and Hall. Second Edition. Chapter 3. Williamson D.I. (2003). theOrigins of Larvae. Kluwer. External links Media related tometamorphosis at Wikimedia Commons thedictionary definition of metamorphosis at Wiktionary vte Developmental biology AgeingCompartmentEmbryogenesis HumanDrosophilaFishpolarityEmbryologyMetamerismLarvaPupaMetamorphos is Indirect development: holometabolism (Hypermetamorphosis), hemimetabolismDirect development: ametabolismModel organismsOntogenyPubertyRegeneration HumanTeratology Evolutionary developmental biology

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List of last words (20th century) Pelisson, Anaele (24 October 2017). "8 'famous last words' that were probably made up". Business Insider. Retrieved 25 October 2019. "ACCIDENT INVESTIGATION... 325 KB (35,675 words) - 15:23, 19 June 2024 

List of last words (19th century) 'famous last words' that were probably made up". Business Insider. Retrieved 25 October 2019. Rickett, Oscar (2 August 2015). "Famous last words? Say them... 183 KB (20,870 words) - 06:13, 10 June 2024 

List of last words (18th century) dies." thestory of Addison's last words is disputed. Marvin expresses doubt about theauthenticity of these last words.: 183 Also reported as, "The Catholic... 74 KB (8,765 words) - 06:13, 10 June 2024

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List of songs about abortion their own words: songwriters talk about thecreative process. Praeger Publishers. pp. 208–209. ISBN 0-275-98402-8. Willman, Chris. (December 1, 2000). "Shady... 143 KB (16,378 words) - 17:39, 2 May 2024

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Numeronym Microsoft Encarta College Dictionary, it originally referred tophonewords – words spelled by theletters of keys of a telephone pad. A numeronym can also... 9 KB (942 words) - 14:55, 17 May 2024

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Corporate jargon (redirect from Business speak) Corporate jargon (variously known as corporate speak, corporate lingo, business speak, business jargon, management speak, workplace jargon, corporatese, or commercialese)... 12 KB (1,233 words) - 22:29, 1 April 2024

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List of gairaigo and wasei-eigo terms (redirect from Japanese words of english origin) Gairaigo are Japanese words originating from, or based on, foreign-language (generally Western) terms. These include wasei-eigo (Japanese pseudo-anglicisms)... 72 KB (569 words) - 23:31, 10 May 2024

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List of Generation Z slang Retrieved 2024-02-17. "9 slang words teens and Gen Zers are using in 2020 - and their boomer equivalents". Business Insider. Archived from theoriginal... 107 KB (4,549 words) - 23:26, 22 June 2024 

English language (redirect from Number of words in theEnglish language)

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small subset of English vocabulary (about 1500 words, designed torepresent thehighest use in international business English) in combination with thestandard... 234 KB (23,649 words) - 13:28, 22 June 2024 

Abby Lee Miller International Business Times. February 10, 2014. Retrieved February 22, 2023. "My Dad, George L. Miller died on Father's Day in 2000 – I miss him every... 28 KB (2,744 words) - 08:12, 20 June 2024 

List of common misconceptions (redirect from List of popular misconceptions about science) reversal of letters or words, or mirror writing, is not included in thedefinition of dyslexia. Dinelli B. "Common Misconceptions about Dyslexia". Commonwealth... 568 KB (55,231 words) - 06:32, 23 June 2024

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List of loanwords in Indonesian (redirect from List of borrowed words in Indonesian) peranakan are themost successful when it comes tobusiness, trade, and cuisine.[citation needed] Words of Chinese origin (presented here with accompanying... 100 KB (2,922 words) - 14:54, 6 June 2024

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Dogpile

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2019. WIRED Staff (July 26, 2000). "InfoSpace Pays $4 Bil forGo2Net". Wired. ISSN 1059-1028. Retrieved January 28, 2019. "About Dogpile - Dogpile". InfoSpace... 12 KB (1,121 words) - 16:22, 16 June 2024 

List of last words A person's last words, their final articulated words stated prior todeath or as death approaches, are often recorded because of thedecedent's fame, but... 162 KB (19,658 words) - 06:12, 10 June 2024 

Chairperson A. (2000). theOxford dictionary of American usage and style (2 ed.). Oxford: Oxford University Press. p. 61. ISBN 0-19-513508-3. "Banned words". The... 32 KB (3,243 words) - 03:51, 18 June 2024

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Peace Sells... but Who's Buying? "Rattlehead" from their debut album, Killing Is My Business... and Business Is Good! Speaking about thelyrical content of Peace Sells..., Mustaine and... 40 KB (3,623 words) - 16:48, 20 June 2024 

Pussy (category English words) similar words exist in other European languages, including Lithuanian puižė and Irish puisín, both traditional calls toattract a cat. thewords puss and...

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List of Peabody Award winners (2000–2009) to Heroes NBC and John Wells Productions Third Watch, for"In Their Own Words," a stand-alone profile of real-life responders tothe9/11 attack on New... 55 KB (78 words) - 23:19, 19 May 2024

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Lisa Lopes struggled with self-harm and even carved thewords "hate" and "love" into her arm with a razor. In September 2000, Lopes was reported missing after failing... 46 KB (5,079 words) - 10:55, 20 June 2024

From Wikipedia, thefree encyclopedia For theTejano singer, see Lisa Lopez. Lisa Lopes Lopes as featured in Black Enterprise magazine c. 2001 Born Lisa Nicole Lopes May 27, 1971 Philadelphia, Pennsylvania, U.S. Died April 25, 2002 (aged 30) La Ceiba, Honduras Resting place

Hillandale Memorial Gardens, Lithonia, Georgia, U.S.

Other names Left EyeN.I.N.A. Occupations Rappersingersongwriter Years active Partners

1990–2002[1]

Andre Rison (1993–2001)

Sean Newman (2000)[2][3] Musical career Origin

Atlanta, Georgia, U.S. Page 1363

Genres Hip hoppopR&B Instrument(s)

Vocals

Labels LaFaceAristaDeath Row Formerly of TLC Website

www.lisalopesfoundation.net

Lisa Nicole Lopes (May 27, 1971 – April 25, 2002), better known by her stage name Left Eye, was an American rapper and singer. She was a member of theR&B girl group TLC, alongside Tionne "T-Boz" Watkins and Rozonda "Chilli" Thomas. Besides rapping and singing on TLC recordings, Lopes was thecreative force behind thegroup, receiving more co-writing credits than theother members. She also designed some of their outfits and thestage fortheir FanMail Tour and contributed tothegroup's image, album titles, artworks, and music videos. Through her work with TLC, Lopes won four Grammy Awards.[4] During her brief solo career, Lopes scored two US top 10 singles with "Not Tonight" and "U Know What's Up", as well as one UK number-one single with "Never Be theSame Again", thelatter a collaboration with Melanie C of theEnglish girl group Spice Girls. She also produced another girl group, Blaque, who scored a platinum album and two US top 10 hits. Lopes remains theonly member of TLC tohave released a solo album. On April 25, 2002, Lopes was killed in a car accident in Roma, Jutiapa, Honduras, while volunteering at a children's development center. Lopes was speeding and lost control of her rental SUV. Four other passengers were injured enough torequire hospitalization.[5] thedocumentary theLast Days of Left Eye was released and aired on VH1 in May 2007. Early life Lisa Nicole Lopes was born on May 27, 1971, in Philadelphia, thedaughter of LaWanda (née Andino), a seamstress, and Ronald Lopes Sr., a US Army staff sergeant.[6] Lisa has a younger brother, Ronald Jr., and a younger sister, Rain (nicknamed Reigndrop).[7] Lopes said her father was "very strict, very domineering" and that he treated thefamily like they were in "boot camp".[8][9] He was also a "talented musician" who played theharmonica, clarinet, piano, and saxophone.[10] Page 1364

Lopes' parents separated when she was still in school, and her paternal grandmother raised her during thelater years of her childhood.[11] She began playing with a toy piano at five years old, and later composed her own songs. By age 10, Lopes formed themusical trio theLopes Kids with her siblings, with whom she performed gospel songs at local events and churches.[10] She attended thePhiladelphia High School forGirls.[12] In an interview with theIndependent, Lopes said that at 14 she was moved after hearing theQueen Latifah and Monie Love song "Ladies First".[13] Career 1990–1999: TLC Main article: TLC (group) In late 1990,[9] Lopes moved toAtlanta todance in an artist's music video.[11] TLC originally started as a female trio called '2nd Nature', with T-Boz, Left Eye and Crystal. thegroup was renamed TLC, derived from thefirst initials of its members at thetime: Tionne Watkins, Lisa Lopes and Crystal Jones.[14][15] Things did not work out with Jones, and TLC's manager Perri "Pebbles" Reid brought in Damian Dame backup dancer Rozonda Thomas as a third member of thegroup.[16] topreserve theband's original name, Thomas needed a name starting with C, which is how she became "Chilli", a name chosen by Lopes. Watkins became T-Boz, derived from thefirst letter of her first name and "Boz" (slang for"boss"). Lopes was renamed "Left Eye" after a compliment from her friend, speculated tobe New Edition member Michael Bivins, who once told her he was attracted toher because of her left eye, which was more slanted than her right eye. Lopes emphasized her nickname by wearing a pair of glasses with theright lens covered by a condom in keeping with thegroup's support of safe sex, wearing a black stripe under her left eye, and eventually getting her left eyebrow pierced.[7] The group debuted in 1992 with thealbum Ooooooohhh... On theTLC Tip.[15] With four hit singles, it sold six million copies worldwide, leading tothegroup becoming a household name. Shortly afterwards, Lopes began dating Atlanta Falcons football player Andre Rison, and thetwo soon moved in together in Rison's upscale double-story home. Their relationship was allegedly filled with violent moments, and Lopes filed an assault charge against Rison on September 2, 1993. Lopes had a battle with alcohol at thetime, having started drinking at theage of fifteen. After another fight between thecouple, in theearly morning hours of June 9, 1994, Lopes tossed numerous pairs of Rison's newly purchased sneakers into a bathtub and lit them on fire.

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thefiberglass bathtub quickly melted and set thestructural frame of thehouse on fire. Lopes and Rison had had a fight previously because she caught Rison in bed with another woman. Lopes had thrown numerous teddy bears Rison had bought her into thetub and lit them on fire. Rison then had thedamaged marble tub replaced with a cheaper fiberglass model, which went up in flames immediately when she set theshoes on fire. Lopes was arrested and indicted on charges of first-degree arson; she was sentenced tofive years of probation and a $10,000 fine. Rison eventually reconciled with Lopes, and they continued dating on and off forseven years.[17] Shortly after, CrazySexyCool was released, selling over 23 million copies worldwide. However, Lopes' stint in rehab had led toher only having limited input in thewriting and recording of thealbum. After therelease of CrazySexyCool, Lopes was a featured artist forthefirst time on "How Do You Like It?" a song by Keith Sweat in 1994. Later in 1995, Lopes recorded a wellreceived verse totherap version of "Freedom" of thesoundtrack from theBlack Panther-based docudrama Panther with fellow female hip hop artists such as Queen Latifah, MC Lyte, Patra, Yo-Yo, Salt 'n' Pepa and Meshell Ndegeocello. In 1997, Lopes was featured on theremix toLil' Kim's "Not Tonight", alongside Missy Elliott, Angie Martinez and Da Brat. thesingle earned all artists a nomination forBest Rap Performance by a Duo or Group at the1998 Grammy Awards. TLC's third album, FanMail, was released in 1999 and sold over 14 million copies worldwide. thealbum's title was named by Lopes as a tribute toTLC's loyal fans and thesleeve contained thenames of hundreds of fans screen names as a "thank you".[18] During and after therelease of FanMail, Lopes made it known tothepress on multiple occasions that she felt that she was unable toexpress herself in TLC fully. Her contributions tosongs had been reduced toperiodic eight-bar raps, and there were several songs in which she had no vocals. Studio session singers such as Debra Killings often sang background vocals forChilli. In theMay 1999 issue of Vibe magazine, Lopes said, "I've graduated from this era. I cannot stand 100 percent behind this TLC project and themusic that is supposed torepresent me."[19][20] In response toLopes' comments, Watkins and Thomas stated toEntertainment Weekly that Lopes "doesn't respect thewhole group" and "Left Eye is only concerned with Left Eye." In response, Lopes sent a reply through Entertainment Weekly issuing a "challenge" toWatkins and Thomas torelease solo albums and let thefans decide thewinner of TLC. Not only would it be entertaining, but more importantly, thethree albums would fulfill their contractual obligations and end their deal with LaFace Records:

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I challenge Tionne Watkins (T-Boz) and Rozonda Thomas (Chilli) toan album entitled "The Challenge"... a 3-CD set that contains three solo albums. Each [album]... will be due totherecord label by October 1, 2000... I also challenge Dallas 'The Manipulator' Austin toproduce all of thematerial and do it at a fraction of his normal rate. As I think about it, I'm sure LaFace would not mind throwing in a $1.5 million prize forthewinner.[21] Watkins and Thomas were unconvinced by thestrategy behind 'The Challenge' and declined totake up theoffer, though Lopes remained firm in her support fortheidea.[22] Things were heated between theband forsome time, with Thomas speaking out against Lopes, calling her antics "selfish", "evil", and "heartless".[23] TLC then addressed these struggles by saying that they are very much like sisters who have their disagreements every now and then as Lopes explained, "It's deeper than a working relationship. We have feelings foreach other, which is why we get so mad at each other. I usually say that you cannot hate someone unless you love them. So, we love each other. That's theproblem."[24] 1998–2002: Solo career In 1998, Lopes hosted theshort-lived MTV series theCut, in which a list of aspiring pop stars, rappers, and rock bands competed against each other in front of judges. theshow's winner, which ended up being a male-female rap duo named Silky, was promised a record deal and funding toproduce a music video, which would then enter MTV's heavy rotation. A then-unknown Anastacia finished in third place, but ended up securing a record deal after Lopes and theshow's three judges were impressed by her performance.[25] Lopes created Left Eye Productions todiscover new talent.[26] She mentored theR&B trio Blaque, and helped them secure a record deal with Columbia Records.[27] Their self-titled debut album was executive-produced by Lopes, who also made a cameo appearance in their music video "808" and also rapped in their second music video "I Do". Lopes was also developing and promoting another new band called Egypt.[26] They worked with Lopes on her second album under her new nickname, N.I.N.A., meaning New Identity Not Applicable.[28] She was also featured on Method Mans second album Judgement Day on thesong "Cradle Rock". In 2000, Lopes became a featured rapper on several singles, including Spice Girls Melanie C's "Never Be theSame Again", which topped thecharts in 35 countries, including theUnited Kingdom.[29] She was also featured on "U Page 1367

Know What's Up", thefirst single from Donell Jones' second album, Where I Wanna Be,[30] and she rapped a verse in "Space Cowboy" with NSYNC on their 2000 album, No Strings Attached.[31] On October 4, 2000, Lopes cohosted theUK's MOBO Awards with Trevor Nelson, where she also performed "U Know What's Up" with Jones.[32][33] She also collaborated on "Gimme Some" by Toni Braxton forher 2000 album theHeat.[34] She had previously featured on Keith Sweat's song "How Do You Like It?".[35] In 2001, she appeared in a commercial forthefashion brand Gap. In July 2001, Lopes appeared on thesingers' edition of Who Wants toBe a Millionaire along with Joey McIntyre, Tyrese, Nick Lachey, and Lee Ann Womack.[36] She dropped the$125,000 question and won $32,000 forher charity.[37] After her death in 2002, theepisode she appeared in was shown in dedication toher.[citation needed] In 2008, Lopes' family opened UNI Studios, which she had created forthepurpose of recording solo projects, tothepublic.[38][39] Her brother Ronald is thegeneral manager of thestudio. Lopes had a dream of making new artists able torecord music at a low cost, in a high-end studio at her house. Her family continues tooperate it and fill it with new equipment.[40] Supernova Lopes spent much of her free time after theconclusion of TLC's first headlining tour, theFanMail Tour, recording her debut solo album, Supernova. It includes a song titled "A New Star is Born", which is dedicated toher late father. She told MTV News: That track is dedicated toall those that have loved ones that have passed away. It's saying that there is no such thing as death. We can call it transforming fora lack of better words, but as scientists would say, 'Every atom that was once a star is now in you.' It's in your body. So, in thesong I pretty much go along with that idea. ... I don't care what happens or what people think about death, it doesn't matter. We all share thesame space.[41] Other tracks covered other personal issues, including her tumultuous relationship with Rison. Among thealbum's 13 tracks was also a posthumous duet with Tupac Shakur that was assembled from thelarge cache of unreleased recordings done prior tohis murder in 1996. Initially scheduled forrelease on a date tocoincide with the11th anniversary of her grandfather's death, Arista Records decided todelay and then cancel theAmerican release.[42] thealbum was eventually released in August 2001 in different Page 1368

foreign countries. theJapanese import includes a bonus track called "Friends", which would later be sampled for"Give It toMe While It's Hot" on TLC's fourth album 3D. N.I.N.A. After numerous talks with Death Row Records CEO Suge Knight, Lopes severed her solo deal with Arista (despite remaining signed tothelabel as a member of TLC) and signed with Knight's Death Row Records in January 2002, intending torecord a second solo album under thepseudonym "N.I.N.A." (New Identity Not Applicable). She had discussions about recording with David Bowie fortheproject,[43] whom she was also trying toget involved with thefourth TLC album. theproject was also planned toinclude collaborations with Ray J along with close friend Missy Elliott.[44][45] After Lopes' death in April 2002, Death Row Records still had plans tocomplete and release thealbum (unfinished at thetime of Lopes' death[46][47]) in October 2002, but thealbum was cancelled forunknown reasons. Several tracks from thealbum were leaked online featuring artists from Tha Row Records. Lopes's unreleased songs were also sampled by TLC fortheir fourth album 3D after she died. Another track, "Too Street 4 T.V" (featuring Danny Boy), was released on thesoundtrack tothe2003 film Dysfunktional Family. 2008–2012: Eye Legacy In 2008, Lopes' family decided towork with producers at Surefire Music Group tocreate a posthumous album in her honor, Eye Legacy. Originally set tobe released October 28, 2008, therelease date was pushed back toNovember 11, then toJanuary 27, 2009. thesong 'Neva Will Eye Eva' and "Crank It", both feature and were co-produced by Lopes' sister Raina "Reigndrop" Lopes. thefirst official single from thealbum, "Let's Just Do It", was released on January 13, 2009, and features Missy Elliott and TLC. thesecond official single, "Block Party", features Lil Mama. thealbum largely consists of reworked versions of tracks from theSupernova album. In November 2009, Forever... theEP was released which contained international bonus tracks not used on theEye Legacy album. theEP was only available todownload. In 2012, on theeve of thetenth anniversary of her death, "Fantasies", an unreleased track by Bootleg featuring Lopes, was uploaded toSoundCloud.[48] Personal life

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Lopes was often vocal about her personal life and difficult past. She came from an abusive, alcoholic background and struggled with alcoholism herself.[9] These issues became headline news in 1994, when she was arrested forsetting fire toAndre Rison's sneakers in a bathtub; thefire ultimately spread tothemansion they shared and destroyed it. She claimed that Rison had beaten her after a night out, and she set fire tohis shoes toget back at him, but burning down thehouse was an accident. Lopes later revealed that she did not have a lot of freedom within therelationship and that Rison abused her emotionally and physically; she said that she released her frustrations about therelationship on thenight of thefire.[17] Lopes was sentenced tofive years' probation and therapy at a halfway house, and was unable toshake theincident from her reputation.[7] Lopes revealed in theLast Days of Left Eye that her meeting with a struggling mother in rehab left a big impression on her.[49] She subsequently adopted thewoman's 8-year-old daughter. She had adopted a 12-year-old boy ten years prior.[50] Lopes had several tattoos. Most prominent was a large eagle on her left arm, which she said represented freedom. Later, she added thenumber "80" around theeagle, which was Rison's NFL number while in Atlanta.[13] She also had a tattoo of a moon with a face on her foot in reference toRison's nickname, "Bad Moon." On her upper right arm was a large tattoo of thename "Parron" forher late stepbrother who died in a boating accident, arching over a large tattoo of a pierced heart. Her smallest tattoo was on her left earlobe and consisted of an arrow pointing toher left over thesymbol of an eye, a reference toher nickname.[51] Lopes struggled with self-harm and even carved thewords "hate" and "love" into her arm with a razor.[52] In September 2000, Lopes was reported missing after failing toattend a family gathering and a major press conference in Las Vegas.[53][54] Roughly two weeks before her own death, Lopes was a passenger in a traffic accident that resulted in thedeath of a 10-year-old Honduran boy.[7] As reported in Philadelphia Weekly, "It is commonplace forpeople towalk theroads that wind through Honduras, and it's often difficult tosee pedestrians." theboy, Bayron Isaul Fuentes Lopez, was following behind his brothers and sisters when he stepped off themedian strip and was struck by a van driven by Stephanie, Lopes' personal assistant. Lopes' party stopped and loaded theboy into thecar, and Lopes "cradled thedying boy's bleeding

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head in her arms" while "someone gave him mouth-to-mouth resuscitation as they rushed him toa nearby hospital."[55] He died thenext day. Lopes paid approximately $3,700 forhis medical expenses and funeral,[7] and she gave thefamily around $925 forany extra costs, although it was apparently agreed upon by theauthorities and theboy's family that his death was an "unforeseeable tragedy" and no blame was placed on thedriver of thevan or Lopes.[55] In thedocumentary theLast Days of Left Eye, Lopes is shown choosing a casket forthechild from a local funeral home. Earlier in thedocumentary, Lopes mentioned that she felt thepresence of a "spirit" following her, and was struck by thefact that thechild killed in theaccident shared a similar last name, even thinking that thespirit may have made a mistake by taking his life instead of hers.[49] Death and funeral Lopes's grave at Hillandale Memorial Gardens On April 25, 2002, Lopes was driving a rented Mitsubishi Montero SUV in La Ceiba, Honduras, when she swerved toavoid a truck then sharply totheleft as she tried toavoid an oncoming car. thevehicle rolled several times after hitting two trees, throwing Lopes and three others out of thewindows, and finally coming torest in a ditch at theside of theroad. Lopes, aged 30, died instantly of "fracture of thebase of thecranium" and "open cerebral trauma", and was theonly person fatally injured in thecrash. She was not wearing a seat belt. thecollision was recorded on video from inside thevehicle because a documentary film was in progress.[56] Lopes' funeral was held at New Birth Missionary Baptist Church in Lithonia, Georgia, on May 2, 2002.[57][58] Thousands of people attended.[59] Engraved upon her casket were thelyrics toher portion of "Waterfalls", stating "Dreams are hopeless aspirations, in hopes of coming true, believe in yourself, therest is up tome and you."[60] Gospel duo Mary Mary sang their song "Shackles (Praise You)" at thefuneral.[61] Lopes was buried at Hillandale Memorial Gardens in Lithonia.[62] Legacy In a statement toMTV, music producer Jermaine Dupri remembered Lopes: "She was determined tobe something in life. She was a true rock star. She didn't care about no press. She was therock star out of thegroup. She was theone that would curse on TV. She had thetattoos. You could expect

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theunexpected. When you see Lisa, you could expect something from her. That's thegift she carried."[41] Lopes was in theprocess of setting up two educational centers forHonduran children. One was built on an 80-acre plot of land she called Camp YAC. theother center was called Creative Castle.[63] In 2003, shortly after Lopes' death, her family started theLisa Lopes Foundation, a charitable group dedicated toproviding neglected and abandoned youth with theresources necessary toincrease their quality of life.[64] Her spiritual motto was theone used forher foundation: "Energy never dies... it just transforms." Her foundation went into various underdeveloped villages and gave new clothes topoor children and their families. In August 2007, thefoundation hosted a charity auction, selling items donated by celebrities. It raised approximately $5,000 fortheHogar de Amor ("Home of Love"), an orphanage in Honduras.[64] In 2012, thefoundation began hosting an annual music festival, known as "Left Eye Music Fest", in Decatur, Georgia.[65] In the2018 Boots Riley film Sorry toBother You, members of a fictional activist group called "Left Eye" use as their symbol a stripe of eye black under theleft eye, in an unmentioned reference toLopes.[66] Posthumous documentary A documentary showing thefinal 27 days of Lopes' life, titled theLast Days of Left Eye, premiered at theAtlanta Film Festival in April 2007, foran audience that included many of Lopes' contemporaries, including Monica, Ronnie DeVoe, 112, Big Boi, India.Arie, and Cee Lo Green.[17][67] VH1 and VH1 Soul broadcast thedocumentary on May 19, 2007. Most of thefootage was shot with a handheld camera, often in theform of diary entries filmed by Lopes while on a 30-day spiritual retreat in Honduras with sister Reigndrop, brother Ronald and members of theR&B group Egypt.[68] In these entries, she reflected on her personal life and career. A calmer side of her personality was on display, showing interests in numerology and yoga.[49] In January 2020, Lifetime aired an episode of Hopelessly In Love, a docuseries that captures therelationships of therich and famous, about Lopes and Rison's tumultuous relationship. It showcased thecomplexity of their relationship and how she ended up with a felony arson charge forburning down Rison's Atlanta mansion. Discography

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Main article: Lisa Lopes discography See also: TLC discography Studio albums Supernova (2001) Eye Legacy (2009) Filmography Year Title

Role

1994 House Party 3

Sex as a Weapon (with TLC)

1995 Living Single Herself (with TLC) 1998 The Cut

Herself (presenter)

2000 Bamboozled

Herself

2001 Cousin Skeeter

Brenda

2007 The Last Days of Left Eye Herself (archive footage) 2013 CrazySexyCool: theTLC Story

Herself (archive footage) (VH1 biopic)

2020 Hopelessly in Love: Lisa "Left Eye" Lopes and Andre Rison (archive footage) (Lifetime documentary)

Herself

2023 TLC Forever Herself (archive footage) (Lifetime documentary) References Steve Huey. "TLC". AllMusic. Retrieved December 2, 2019. "Jet". Johnson Publishing Company. October 11, 1993. Retrieved December 5, 2017. "Ebony". Johnson Publishing Company. August 1, 2002. Retrieved December 5, 2017. "Grammy.com". Retrieved May 16, 2012. Reid, Shaheem (April 26, 2002). "Lisa 'Left Eye' Lopes Killed In Car Accident: TLC singer in fatal car accident in Honduras". MTV. MTV. Retrieved July 28, 2023. Keeps, David A. (June 6, 2002). "Life of Fiery Rapper Lisa Lopes Tragically Cut Short". Rolling Stone. Archived from theoriginal on April 10, 2014. Retrieved February 8, 2014.

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"Remembering Lisa 'Left Eye' Lopes". BET. "Chilli, T-Boz, Jermaine Dupri Remember TLC's Left Eye". MTV. April 26, 2002. Retrieved August 25, 2013. Reid, Shaheem (September 6, 2002). "Suge Knight Plans toRelease Left Eye's 'N.I.N.A.' LP". MTV News. Retrieved March 8, 2014. Reid, Shaheem; Vineyard, Jennifer (April 26, 2002). "Lisa 'Left Eye' Lopes Killed in Car Accident". MTV News. Retrieved March 8, 2014. Moss, Corey; Johnson, Tina (January 3, 2002). "Left Eye Signs With Suge Knight's Tha Row". MTV News. Retrieved March 8, 2014. Reid, Shaheem (November 11, 2002). "Kurupt Hits Big Screen, Talks Lisa Lopes Album, Tha Row". MTV. Retrieved June 26, 2013. "Lisa 'Left Eye' Lopes - 'N.I.N.A'". Capital XTRA. Archived from theoriginal on June 14, 2018. Retrieved June 5, 2018. Paine, Jake (November 5, 2013). "Left Eye Was Making an Album forDeath Row When She Died". L.A. Weekly. Retrieved June 5, 2018. ""Fantasies" - Bootleg (of Dayton Family) ft. Lisa "Left Eye" Lopes". SoundCloud. Lazin, Lauren (Director) (May 19, 2007). theLast Days of Left Eye (Documentary film). United States: VH1. TLC time forLisa Lopes Archived July 29, 2012, at theWayback Machine Tour Dates. Retrieved April 29, 2009. "entry". Vanishingtattoo.com. July 4, 2007. Archived from theoriginal on June 11, 2012. Retrieved November 12, 2010. "Documentary Recounts theLast Days of Left Eye". NPR.org. Retrieved April 13, 2020. "TLC pop star missing in theUS". BBC News. Retrieved June 17, 2020. "TLC rapper goes missing". NME. September 8, 2000. Retrieved June 17, 2020. Jones, Solomon (August 14, 2002). "Over theWaterfall". Philadelphia Weekly. Retrieved January 12, 2017.[permanent dead link] "Autopsy: theLast Hours of Lisa 'Left Eye' Lopes." Autopsy: theLast Hours of.... Nar. Eric Meyers. Exec. Prod. Suzy Davis, Ed Taylor, and Michael Kelpie. Reelz, 24 Mar. 2019. Television. Susman, Gary (April 30, 2002). "Bad Car-ma". Entertainment Weekly. Archived from theoriginal on October 23, 2013. Retrieved February 8, 2014. "Thousands Gather toSay Goodbye toLeft Eye". MTV. May 2, 2002. Retrieved February 8, 2014.

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"Thousands mourn 'Left Eye'". BBC News. May 3, 2002. Retrieved February 8, 2014. "Thousands attend Lopes funeral". BBC News. May 3, 2002. Retrieved December 27, 2017. "Left Eye Funeral Draws Thousands". Eonline.com. May 2, 2002. Retrieved April 1, 2020. "'Left Eye' laid torest". NME. May 2, 2002. Retrieved December 27, 2017. Silverman, Stephen M. (April 30, 2002). "The Idyllic Last Days of Lisa Lopes". People. Retrieved January 12, 2017. Dines, Kaylyn Kendall (August 23, 2007). "Lisa Lopes Foundation fundraiser helps orphans in Honduras". New York Amsterdam News. Vol. 98, no. 35. p. 24. ISSN 0028-7121.[dead link] "The Lisa Lopes Foundation Announces 1st Annual Left Eye Music Fest on July 28th in Atlanta". PRWeb. April 19, 2012. Archived from theoriginal on July 1, 2018. Retrieved December 28, 2017. Serpell, Namwali (July 21, 2018). "Sorry toBother You: Boots Riley's Trojan Horseplay". theNew York Review of Books. Retrieved August 15, 2018. ""Last Days of Left Eye" and "Fay Grim" Bookend 31st Atlanta Film Fest". Indiewire. April 18, 2007. Retrieved February 8, 2014. Hefferan, Virginia (May 19, 2007). "Last Days of Left Eye". theNew York Times. Archived from theoriginal on July 27, 2013. Retrieved February 8, 2014. External links Wikimedia Commons has media related toLisa Nicole Lopes. Lisa Lopes Foundation Archived June 11, 2012, at theWayback Machine Lisa Lopes at IMDb Lisa "Left Eye" Lopes on Grammy Awards "Lisa Lopes' Daughter". Alevemente. February 12, 2024. Retrieved April 23, 2024. vte Lisa Lopes vte TLC Authority control databases Edit this at Wikidata

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Categories: 1971 births2002 deathsAfrican-American women rappersAfricanAmerican pianistsAfrican-American women singer-songwritersAfricanAmerican songwritersAmerican contemporary R&B singersAmerican women singer-songwritersPop rappersAmerican people convicted of arsonAmerican people of Portuguese descentAmerican women pianistsBurials in Georgia (U.S. state)Death Row Records artistsFilmed deaths of entertainersMusicians from PhiladelphiaPhiladelphia High School forGirls alumniRappers from AtlantaRappers from PhiladelphiaRoad incident deaths in HondurasSingersongwriters from PennsylvaniaTLC (group) members20th-century American pianists20th-century American singer-songwriters20th-century American women singers21st-century American singer-songwriters21st-century American women singers20th-century women rappers21st-century American women rappers21st-century American rappersSinger-songwriters from Georgia (U.S. state) This page was last edited on 20 June 2024, at 10:55 (UTC). Text is available under theCreative Commons Attribution-ShareAlike License 4.0; additional terms may apply. By using this site, you agree totheTerms of Use and Privacy Policy. Wikipedia® is a registered trademark of theWikimedia Foundation, Inc., a non-profit organization. 2002 2003 2004 2005 2006 2007 2008 2009 References See also List of Peabody Award winners (2000–2009) Article Talk Read Edit Page 1378

View history Tools Appearance hide Text Small Standard Large Width Standard Wide From Wikipedia, thefree encyclopedia The following is a list of George Foster Peabody Award winners and honorable mentions during thedecade of the2000s. 2000 Recipient Area of Excellence Marty Haag Personal Award forhis work as news director at WFAATV/Dallas, TX and as senior vice-president of Broadcast News Operations forBelo CBS News 48 Hours (anchored by Dan Rather), forthereport "Heroes Under Fire" by Bill Lagattuta, which examined thecause and aftermath of theWorcester Cold Storage and Warehouse fire 60 Minutes II, forthereport "Death by Denial", reported by Ed Bradley, which examined theoutbreak of HIV/AIDS in Africa NBC News Dateline NBC, forthereport "The Paper Chase" from correspondent John Larson and reporter Andy Lehren, a look at a "paper file review" of one auto accident victim's medical claim

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KHOU/Houston, TX "Treading on Danger," an investigation by KHOU's Investigative Unit, led by David Raziq, and reporter Anna Werner of failures of Firestone tires on Ford vehicles KBS Chong-Ju An Eighty-Four Year Old Youngful Man Lives in theCabin, directed by Hyun Jin Hong WJXT/Jacksonville, FL Behind Closed Doors, a documentary anchored by Deborah Gianoulis examining treatment of domestic violence victims at Hubbard House P.O.V./American Documentary Inc., National Asian American Telecommunications Association, and Sun Fountain Productions toInform

Regret

HBO, Whiteford-Hadary, University of Maryland, and Tapestry International King Gimp Wall toWall forChannel 4 in association with WNET/New York, NY House

The 1900

Heartlove Productions, Lovett Productions, HBO Cancer: Evolution toRevolution, directed by Joseph F. Lovett and narrated by Lilly Tartikoff WGBH-TV (Boston, MA)/Frontline, co-produced with Rain Media Inc. and Cam Bay Productions Frontline, forDrug Wars, a documentary about thewar on drugs, produced by Martin Smith and with contributors including Lowell Bergman, Doug Hamilton, Kenneth Levis, Brooke Runnette, and Oriana Zill HBO Sports Ali-Frazier 1: One Nation...Divisible, produced by Joseph M. Lavine and Jonathan Crystal CNN Productions, Insight News Television, and Channel Four International CNN Perspectives: Cry Freetown David Grubin Productions Inc. and Devillier Donegan Enterprises (aired on PBS) Napoleon, a four-part series on Napoleon directed by David Grubin BBC, Discovery Channel, and TV Asahi, in association with ProSieben and France 3 Walking with Dinosaurs Marketplace Productions/Minnesota Public Radio, in association with theUniversity of Southern California Marketplace Sound Portraits Productions Witness toan Execution, a feature story on NPR's All Things Considered produced by Jim Willett, Stacy Abramson, David Isay, and David Miller profiling capital punishment in Texas National Public Radio "The NPR 100," a showcase of "the 100 most important American musical works of the20th century", airing on Morning Edition, All Things Considered, and Weekend Edition and produced by Elizabeth Blair

Page 1380

True Vision Productions Ltd. forChannel 4 in association with HBO Slavery, a film by Kate Blewett and Brian Woods on contemporary slavery on multiple continents Katie Couric and NBC News Award forCouric's series "Confronting Colon Cancer" Learning Matters Inc. and theMerrow Report (aired on PBS) School Sleuth: theCase of an Excellent School, produced and presented by John Merrow WGBH-TV/Boston, MA and Cinar

Arthur

Idaho Public Television and Idaho Department of Health and Welfare Hearts and Minds: Teens and Mental Illness, produced by Marcia Franklin WGBH-TV (Boston, MA) Science Unit and Production Group, Inc. Big

Building

NBC and John Wells Productions, in association with Warner Bros. Television The West Wing HBO, Chase Films, and Brad Grey Television

The Sopranos

Robert Greenwald Productions Inc. and Pearson Television International (distributor) (aired on CBS) Sharing theSecret BBC America and WGBH-TV/Boston, MA forDavid Copperfield

ExxonMobil Masterpiece Theatre,

A&E Networks and Columbia TriStar Television in association with Chris/Rose Productions Inc. The Crossing Blown Deadline Productions, Knee Deep Productions, and HBO Fox, Satin City, and Regency Television

The Corner

Malcolm in theMiddle

Mad Cow Productions Inc. in association with Comedy Central Show with Jon Stewart, forits Indecision 2000 series Tiger Aspect Productions forNVC Arts and Channel 4 Bangs

The Daily

Howard Goodall's Big

2001 Recipient Area of Excellence ABC News Separate awards forthenetworks' coverage of theSeptember 11 terrorist attacks National Public Radio Tenth Planet Productions and theU.S. broadcast and cable networks America: A Tribute toHeroes

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NBC and John Wells Productions Third Watch, for"In Their Own Words," a stand-alone profile of real-life responders tothe9/11 attack on New York City Hardcash Productions, Channel 4, and CNN Productions forthedocumentaries Beneath theVeil and Unholy War Touchstone Television (aired on ABC) WNET/New York, NY Dreams

CNN Presents,

Anne Frank: theWhole Story

American Masters, forF. Scott Fitzgerald: Winter

WCPO-TV/Cincinnati Visions of Vine Street, an "I-Team" documentary profiling theCincinnati thoroughfare and theadjacent Over-the-Rhine neighborhood (the epicenter of an April 2001 riot) and theissues that affect thearea Canadian Broadcasting Corporation "A Murder in theNeighbourhood," a report airing on Sunday Edition that profiled a murder in Pickering, Ontario and its effects on thevictim's neighbors Television Broadcasts Limited WTO Challenge Brook Lapping Productions forBBC2, in association with WGBH/Boston, MA, RTÉ, La Sept ARTE, SBS, and YLE Endgame in Ireland 40 Acres and A Mule Filmworks, Luna Ray Films, Black Starz!, KQED/San Francisco, PBS and Black Heritage Network A Huey P. Newton Story Carlton Production in association with theLearning Channel forChannel 4 Hell in thePacific HBO Films, produced in association with theBBC Conspiracy Showtime, Echo Lake Productions, and Sidekick Entertainment Productions Things Behind theSun Avenue Pictures in association with HBO Films

Wit

Wilmore Films, Regency Television, and 20th Century Fox Television The Bernie Mac Show Peter Rosen Productions Inc., KERA-TV/Dallas, TX, and theVan Cliburn Foundation The Cliburn: Playing on theEdge Survival Anglia Ltd. (aired on National Geographic EXPLORER/MSNBC) Mzima – Haunt of theRiverhorse Slow Motion Ltd. (produced forBBC) and WGBH/Boston, MA ExxonMobil Masterpiece Theatre, forTalking Heads II – Miss Fozzard Finds Her Feet Ciesla Foundation and Cinemax

The Life and Times of Hank Greenberg

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Independent Television Service, Paul & Sandra Fierlinger, and AR&T Associates, Inc. (aired on Independent Lens/PBS) Still Life with Animated Dogs SoundVision Productions (distributed by NPR)

The DNA Files

Norman Twain Productions with Shelby Stone Productions in association with HBO Films Boycott Teachers Documentary Project (aired on PBS)

The First Year

National Film Board of Canada (aired on TVOntario's theView from Here) My Father's Camera Youth Radio Institutional Award forthemedia outlet and its training of teenagers in theart of radio production and storytelling Nickelodeon

Little Bill

Blue's Clues WGBH/Boston, MA broadcasting

Institutional Award forits overall excellence in public

CBS News 60 Minutes II, for"Memories of a Massacre," which recounted theThanh Phong raid during theVietnam War Band of Brothers Ltd., on behalf of DreamWorks and Playtone Brothers Nightline

Band of

Institutional Award totheABC News program

National Public Radio

Jazz Profiles

2002 Recipient Area of Excellence ABC News Nightline, for"Heart of Darkness," a series of reports on thewar in theDemocratic Republic of theCongo Nightline, for"The Survivors," a profile of 2 burn victims of the9/11 attack on thePentagon (parts 1 and 2) ALT Films, in association with Paramount Pictures forWGBH/Boston, MA (presented on PBS) ExxonMobil Masterpiece Theatre's American Collection: Almost a Woman London Weekend Television Production forWGBH/Boston, MA, in association with theCanadian Broadcasting Corporation (presented on PBS)

ExxonMobil Masterpiece Theatre: Othello

Page 1383

BBC Radio 4, London, UK File on 4, for"Export Controls," a report revealing how "rogue nations" procured equipment from British companies foruse in their nuclear arms programs Blue Angel Films Ltd., and Tyrone Productions forWNET/New York, NY Stage on Screen: Beckett on Film CBS 9/11 CNN Terror on Tape Court TV, JB Media, and Hearst Entertainment Crowe

The Interrogation of Michael

David E. Kelley Productions, in association with 20th Century Fox Television Boston Public, for"Chapter Thirty-Seven," an episode that dealt with theuse of racial epithets in conversation and its impact ESPN, Bristol, Connecticut, and Lake Champlain Productions The Complete Angler (featuring James Prosek) Fuji Television Network Inc., Tokyo, Japan The Hepatitis C Epidemic: A 15-Year Government Cover-up Greenblatt/Janollari Studios and Actual Size Films Inc., in association with HBO Original Programming Six Feet Under HBO and Simmons/Lathan TV Russell Simmons Presents Def Poetry Kitchen Sisters, Sonic Memorial Collaboration, NPR's Lost & Found Sound, Ben Shapiro Productions, Jamie York Productions, Jay Allison Productions, Radio Diaries, thePublic Collaboration, Picture Projects with dotsperinch The Sonic Memorial Project and SonicMemorial.org, fortheaural chronicling of life around theWorld Trade Center KPRC-TV/Houston, TX "DNA Protects Men of Dishonor," an investigation into prevention of DNA evidence being used in rape cases in theUS Military NBC Studios in association with DreamWorks Television Inc. and Nemo Films Boomtown Nebraska ETV Network forAmerican Experience, a production of WGBH/Boston (presented on PBS)

American Experience: Monkey Trial

Public Television Service Foundation, Taipei, Taiwan theMountain WNET/New York, NY

How High is

EGG, theArts Show

Quest Productions and Video Line Productions forWNET/New York, NY (presented on PBS)

The Rise and Fall of Jim Crow

Page 1384

Scott Free Productions, in association with HBO Films and BBC Films The Gathering Storm SET Productions and C-Films Productions forWGBH/Boston, in association with France2, Abu Dhabi Television, and Tel-Ad Israel (presented on PBS) Oslo

Frontline: Shattered Dreams of Peace, theRoad From

Showtime Networks Inc., in association with Viacom Productions Inc., and A Jersey Guys Production Bang Bang You're Dead Sound Portraits Productions (presented on National Public Radio)

Yiddish Radio Project

Talkback Productions forBBC America via BBC Films and Single Drama Almost Strangers Turner Network Television, Rosemont Productions International Ltd., Angel Brown Productions, in association with Spirit Dance Productions Door toDoor WBEZ-FM, Chicago Public Radio

Stories of Home

WFAA-TV/Dallas, TX "Fake Drugs, Real Lives," a series of reports revealing contrived drug cases investigated by Dallas police WISN-TV/Milwaukee, WI "Sounding theAlarm," a report revealing thelack of effectiveness of smoke alarms on children York Zimmerman Inc., in association with WETA-TV/Washington, D.C. (presented on PBS)

Bringing Down a Dictator

2003 Recipient Area of Excellence CBS News 60 Minutes, forthereport "All in theFamily," (presented by Steve Kroft) which examined political and financial ties between those in theUS government and winners of Defense Department contracts NBC News A Question of Fairness, a Tom Brokaw-led report that profiled theeffects of affirmative action on theUniversity of Michigan Firelight Media forAmerican Experience and WGBH-TV/Boston, MA (airing on PBS)

American Experience, fortheMurder of Emmett Till

Frontline, theNew York Times, and WGBH-TV/Boston, MA (airing on PBS) Frontline, for"A Dangerous Business," which examined deaths and injuries suffered by employees of McWane, a cast-iron pipe maker (Lowell Bergman and David Barstow, correspondents)

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NOVA/WGBH-TV/Boston, MA, in association with David Hickman Films, Sveriges Television and Norddeutscher Rundfunk (presented on PBS)

NOVA, for"The Elegant Universe with Brian Greene"

WNET/New York, NY, co-produced with Idéale Audience, Scorer Associates Ltd., BBC, ARTE France, Opéra National de Paris and NHK, with theparticipation of Musée d'Orsay, AVRO, and SVT (airing on PBS)

Great Performances, forDegas and theDance

P.O.V./American Documentary Inc., Independent Television Service, and National Black Programming Consortium (presented on PBS) P.O.V., forTwo Towns of Jasper, a film on theMurder of James Byrd Jr. directed by Whitney Dow and Marco Williams P.O.V./American Documentary Inc., Independent Television Service, Zula Pearl Films, and National Black Programming Consortium (presented on PBS)

P.O.V., forFlag Wars

Minnesota Public Radio in association with theSan Francisco Symphony American Mavericks, directed by Tom Voegeli and hosted by Suzanne Vega, based on thewritings of Kyle Gann WESH/Orlando, FL and theOrlando Sentinel "Building Homes: Building Problems," a joint investigation into shoddy workmanship in Central Florida's building industry The Irish Film Board, NPS & COBO, RTÉ, BBC, ZDF/ARTE, and YLE (presented on ARTE)

Chavez: Inside theCoup

Viacom, Kaiser Family Foundation, MTV, Noggin/The N, Dancing Toad Productions Award fortheKnow HIV/AIDS and Fight forYour Rights: Protect Yourself campaigns. theaward also cited theMTV documentary theSocial History of HIV and Living with HIV/AIDS, an episode of theN's A Walk in Your Shoes Viacom International, Mango Network, Nickelodeon, and MTV (presented on Nickelodeon) Dora theExplorer KHOU/Houston, TX "Evidence of Errors," an investigation into mistakes made by theHouston Police Department's DNA crime lab KMGH-TV/Denver, CO "Honor and Betrayal: Scandal at theAcademy," a series of reports examining sexual assaults at theUnited States Air Force Academy The University of Memphis

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(presented on AETN and WKNO-TV/Memphis, TN) Hoxie: theFirst Stand, a documentary by David Appleby about theintegration of Arkansas' Hoxie School District BBC (presented on BBC America) The Office BBC Correspondent Production (presented on BBC2) Israel's Secret Weapon, a report by Olenka Frenkiel airing on BBC2's Correspondent series examining thesecrecy behind Israel's nuclear weapons production The NewsHour with Jim Lehrer and MacNeil/Lehrer Productions Award for"Jobless Recovery: Non-Working Numbers," Paul Solman's report examining theinadequacy of government unemployment data WCNC-TV/Charlotte, NC Award foran investigation into dental clinics in North Carolina who sought millions of dollars in Medicaid reimbursement TV Asahi

Mother Flew Away as a Kite

Bill Moyers Personal Award forMoyers' career of "excellence in theuse of television toeducate, inform, and challenge received ideas" Down toEarth Productions (presented on WEKU/Richmond, KY) Sisters in Pain Bachrach/Gottlieb Production (presented on Showtime)

Soldier's Girl

KRON-TV/San Francisco, CA and Young Broadcasting Students Rising Above, a series hosted by Wendy Tokuda and reported by Noel Cisneros and Catherine Heenan about at-risk high school students Blown Deadline Productions in association with HBO Original Programming The Wire TV 2 (Denmark), Cinemax, HBO, and BBC To Live is Better Than toDie, a film about HIV/AIDS in China directed by Weijun Chen Christian Frei Filmproductions in association with Swiss National Television and Suissimage and Cinemax (presented on HBO)

War Photographer

Atlantic Public Media Award fortheTransom.org website and its showcasing of and resource forpublic radio producers 2004 Recipient Area of Excellence

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CBS News 60 Minutes II, fora report by Dan Rather examining abuse and torture of prisoners by US Army and CIA personnel at Iraq's Abu Ghraib prison National Public Radio Award forthenetwork's reportage of theIraq War by Anne Garrels, Ivan Watson, Deborah Amos, Lourdes Garcia-Navarro, Emily Harris, Peter Kenyon, Phillip Reeves, Eric Westervelt, Tom Gjelten, and Mike Shuster WNYC/New York, NY and National Public Radio On theMedia WNYC/New York, NY and Public Radio International Studio 360 American Icons, fortheepisode examining Herman Melville's Moby-Dick Wisconsin Public Radio and Public Radio International To theBest of Our Knowledge Endor Productions in association with BBC and BBC America State of Play Hat Trick Productions and BBC America

The Kumars at No. 42

BBC Television News Separate awards forthenetworks' reports on thecivil war and genocide in theSudanese region of Darfur. Andrew Harding, Ishbel Matheson, Hilary Andersson, Fergal Keane, Nicholas Witchell, Paul Wood, and Bridget Kendall reported fortheBBC and Seth Doane reported forChannel One News. Channel One News Comedy Central The Daily Show with Jon Stewart forIndecision 2004 WBAL-TV/Baltimore, MDAward foran investigation by John Sherman revealing leaks of untreated sewage from a Centreville, MD treatment plant into thewaters feeding Chesapeake Bay and motivations by area political and business officials tocover it up WTVF/Nashville, TN "Friends in High Places," a multi-year investigation led by Phil Williams, Bryan Staples, and Chris Clark into theawarding of no-bid state contracts tofriends of former Tennessee governor Don Sundquist WFAA-TV/Dallas, TX State of Denial, a multi-part series reported by Brett Shipp investigating questionable practices by state agencies and major insurance companies involved with theTexas workers compensation system Filmmakers Collaborative, Blueberry Hill Productions forAmerican Experience, WGBH-TV/Boston, MA American Experience, forTupperware! a film by Laurie Kahn about thenamesake product Televisió de Catalunya and Bausan Films in association with Cinemax Reel Life Balseros Zazen Productions in association with Cinemax Reel Life

Page 1388

Bus 174

Clinica Estetico and LisaGay Inc. in association with HBO Woman Speaks

Beah: A Black

Cort/Madden Productions in association with HBO Films theLord Made

Something

Red Board Productions and Paramount Television in association with HBO Entertainment Deadwood Discovery Channel and Vulcan Productions in association with Gemini Productions and Antenna Film Black Sky: theRace forSpace Howe Sound Films and Force Four Entertainment in association with CBC Human Cargo CultureWorks and theWFMT Radio Network Leonard Bernstein: An American Life, hosted by Susan Sarandon and produced by Steve Rowland The Rhythm and Blues Foundation and Public Radio International Let theGood Times Roll, a series on rhythm and blues hosted by Jerry Butler and produced by Alexis Gillespie Link TV

Mosaic: World News from theMiddle East

Nursery Tap, LLC Nursery Tap, Hip toToe, a children's show about theperforming arts created by Juleen Murray Shaw Grant Tinker Personal Award forhis work as CEO of MTM Enterprises and chairman/CEO of NBC Bill Brummel Productions fortheHistory Channel Rwanda: Do Scars Ever Fade?, a film about theRwandan genocide produced by Paul Freedman Univision Award for"Salud es Vida...Enterate!" ("Lead a Healthy Life...Get theFacts!") thebroadcaster's initiative topromote health issues totheLatino community Sesame Workshop, Kwasukasukela, and South African Broadcasting Corporation Takalani Sesame Presents "talk tome...", a campaign promoting discussions about HIV/AIDS with children CNBC The Age of Wal-Mart: Inside America's Most Powerful Company, reported by David Faber WITI/Milwaukee, WI "The Bully Project," an "investigation-turnedcommunity-outreach-program" by Bob Segall examining theissue of school bullying Trio and Post Consumer Media

The N-Word

2005 Recipient Area of Excellence

Page 1389

WLOX/Biloxi, MS Separate awards forthenews outlets' coverage of Hurricane Katrina and its aftermath WWL-TV/New Orleans, LA NBC News CNN TVE China: A Million Steps Ahead Robert Kenner Films, WGBH Educational Foundation, Wisconsin Public Television, Playtone, and BBC American Experience, forTwo Days in October BBC This World, forBad Medicine BBC and BBC America Viva Blackpool BBC, BBC Factual and Learning, and BBC Drama BBC DoNation Season, a programming initiative topromote awareness of organ donations BBC, in association with HBO Documentary Films, Evanston Township (IL) High School, and La Camioneta Children of Beslan, about theBeslan school hostage crisis BBC and WGBH-TV/Boston, MA (co-production) in association with Deep Indigo Bleak House WNET/New York, NY, Grey Water Park Productions, Spitfire Pictures, and Cappa/DeFina Productions, in co-production with Vulcan Productions, BBC/Arena, and NHK American Masters, forNo Direction Home — Bob Dylan Deeble and Stone Productions, NHK, WNET/New York, NY, Granada International, BBC and ZDF The Queen of Trees P.O.V./American Documentary, Inc., Independent Television Service, and Realside Productions P.O.V., forChisholm '72: Unbought & Unbossed Independent Television Service Fierlinger

A Room Nearby, directed by Paul

David E. Kelley Productions in association with 20th Century Fox Television Boston Legal Heel and Toe Films, Shore Z Productions, and Bad Hat Harry Productions, in association with NBC Universal Television Studios House Red House Entertainment forShowtime Original Pictures America, directed by Chris Eyre

Edge of

Comedy Central South Park Canadian Broadcasting Corporation on Music

The Wire: theImpact of Electricity

Page 1390

CBC/Radio-Canada La Première Chaîne What If Winter Never Comes? (Et si l'hiver ne venait plus?) HBO Family

Classical Baby

KNBC/Los Angeles, CA "Burning Questions," a report exposing environmental concerns at a large commercial/residential building project KCNC-TV/Denver, CO "How Far Will theArmy Go?" a report revealing how U.S. Army recruitment officers instruct potential recruits on how tofalsify school grades, diplomas, and drug tests KCET/Los Angeles, CA in association with Sesame Workshop and 44 Blue Productions, Inc. 'A Place of Our Own (Los Ninos en Su Casa) WNYC/New York, NY

Award fortheRadio Rookies Project

KMEX-DT/Los Angeles, CA 15% of theUnited States, a series of reports dealing with issues of theLatino community Documania Films, Sierra Tango Productions, and theHistory Channel Save Our History: Voices of Civil Rights Maha Films (aired on Sundance Channel) The Staircase Distant Horizon/Videovision Entertainment, Anant Singh, Nelson Mandela Foundation, M-Net Exciting Film, and National Film and Video Foundation of South Africa, in association with HBO Films Yesterday Fox Television Studios in association with Sony Pictures Television R&D TV in association with NBC Universal Television Studios Galactica

The Shield

Battlestar

2006 Recipient Area of Excellence Charlotte Street Films, CBC, BBC, ARTE GEIE TV, TV 2, Yle TV2, WDR TV, VRT TV, SVT, VPRO, NRK, ETV, TVE, and European Union Media Plus Program Why We Fight mun2 For My Country? Latinos in theMilitary, produced and directed by Alison Fast and Moises Velez WTNH/New Haven, CT Award foran investigative report by Alan Cohn revealing defective parts on UH-60 Black Hawk utility helicopters NPR "Mental Anguish and theMilitary," an All Things Considered report by Daniel Zwerdling revealing harassment and ostracizing of Iraqi War veterans at Fort Collins, Colorado who sought out treatment formental health problems

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WISH-TV/Indianapolis, IN "Command Mistake," a report produced by Karen Hensel examining an improvised explosive device's effect on an Iraqi War veteran as well as lack of protective padding in soldiers' helmets HBO Documentary Films in association with Feury/Grant Productions and Downtown Community Television Center Baghdad ER HBO Documentary Films in association with 40 Acres A Requiem in Four Acts

When theLevees Broke:

HBO Family The Music in Me,[1] a documentary on young musicians directed by Amy Schatz, Mark Mannucci, Ellen Goosenberg Kent, Diane Kolyer, and Mark Benjamin HBO Sports Billie Jean King: Portrait of a Pioneer, produced by Margaret Grossi Company Pictures and Channel 4 in association with HBO Films BBC, BBC Two, BBC Worldwide, and National Geographic fortheepisode "Born of Fire"

Elizabeth I

Galápagos,

BBC, BBC America, and Talkback Thames Gideon's Daughter Listen Up! Youth Media Network, Polimorfo, iEarn Sierra Leone, La Camioneta, Sawtona, Frame by Frame Fierce, Light House, Spy Hop Productions, Our Voice, and Evanston Township High School Beyond Borders: Personal Stories from a Small Planet, directed by Austin Haeberle (airing on IFC) WTHR/Indianapolis, IN Award fortheinvestigative reports by Bob Segall "Prescription Privacy" (inadequate disposal of customer prescription records by pharmacies) and "Cause forAlarm" (condition of tornado sirens in central Indiana) MediaRites Productions (airing on Public Radio International) Crossing East: Our History, Our Stories, Our America, a radio documentary directed by Dmae Roberts and hosted by George Takei and Margaret Cho ABC News (World News Tonight, Nightline, and ABCNews.com/Blotter) "Conduct Unbecoming," an investigation headed by Brian Ross that verified sexually inappropriate messages sent tocongressional pages by Florida Representative Mark Foley PJ Productions forABC News Out of Control: AIDS in Black America, reported by Peter Jennings and Terry Moran Chocolate Moose Media, Inc. and Quintet Productions Award fortheThree Amigos Campaign, a program tobuild awareness of condom use toprevent HIV/AIDS HearingVoices.com (aired on KUNM-FM) Award forCrossing Borders, a radio documentary hosted by Marcos Martinez and reported by Luis Alberto Urrea, Scott Carrier, Ann Heppermann, Kara Oehler, Guillermo Gómez-Peña, Page 1392

Siamack Sioshansi, and Bronwyn Ximm chronicling stories and theimpact of illegal immigrants from Mexico totheUnited States Touchstone Television (aired on NBC) Home"

Scrubs, fortheepisode "My Way

Touchstone Television (aired on ABC)

Ugly Betty

Be Square Productions, Inc.

Good Eats (airing on Food Network)

Apartment 11 Productions, CBC Newsworld, RDI, Knowledge Network, and Canadian Television Fund Braindamadj'd...Take II, a documentary directed by Paul Nadler about his recovery from a car crash Showtime and Mandalay Television Brotherhood KMOV/St Louis, MO "Left Behind: theFailure of East St. Louis Schools", reported by Craig Cheatham Dateline NBC (NBC News) "The Education of Ms. Groves" (Hoda Kotb, correspondent) which profiled thestruggles of a Teach forAmerica volunteer and her Atlanta middle school class WBEZ/Chicago, IL This American Life, for"Habeas Schmabeas," (reported by Joseph Margulies, Jack Hitt, and Jon Ronson) which examined abuses of Habeas corpus rights Magic Lantern Productions and Channel 4 website

Award fortheFourDocs

The Washington Post and WashingtonPost.com Award for"Being a Black Man," a print and online series reported by Ben de la Cruz and Hamil Harris profiling thelives of contemporary black males StoryCorps Award totheorganization forits "preservation of ideas and emotions, events and experiences" Steeplechase Films, Inc., High Line Productions, Daniel Wolf, Inc., and WNET/New York, NY American Masters, forAndy Warhol: A Documentary Film 60 Minutes (CBS News) Award fora report by Ed Bradley revealing conflicting testimony and botched and/or unethical police and legal procedures surrounding theDuke University rape scandal Rebel Base and Sony Pictures Television "Return of theKing"

The Boondocks, fortheepisode

NBC Universal Television in association with Imagine Entertainment and Film 44 Friday Night Lights Reveille Productions in association with NBC Universal Television 2007 Page 1393

The Office

Recipient Area of Excellence ABC News Bob Woodruff Reporting: Wounds of War – theLong Road Home of Our Nation's Veterans Partisan Pictures, Inc. and WNET/New York, NY

Nature, forSilence of theBees

mtvU Award forHalf of Us, an initiative topromote awareness of depression among college students BBC World, BBC America, and BBC World News America "White Horse Village," which profiled a "verdant, sleepy, near-feudal" hamlet in theChinese interior and its dealings with modernity's encroachment WNYC/New York, NY

The Brian Lehrer Show

HBO Documentary Films in association with Priddy Brothers Jerusalem

To Die in

KNXV-TV/Phoenix, AZ "Security Risks at Sky Harbor," a report revealing TSA lapses at thePhoenix airport Robert Levi Films, Independent Television Service, and Washington Square Films Independent Lens, forBilly Strayhorn – Lush Life Vixen Films and Independent Television Service Sisters in Law (airing on Independent Lens) WSLS-TV/Roanoke, VA Award forthestation's breaking news coverage of theshootings at Virginia Tech and its immediate aftermath Univision Communications Award forYa Es Hora ("It's Time"), a public service initiative encouraging citizenship applications and voter registration by legal US immigrants Texas Heritage Music Foundation

Whole Lotta Shakin`[2]

American Public Media Speaking of Faith: theEcstatic Faith of Rumi American Public Media and San Francisco Symphony The MTT Files Bravo, theWeinstein Company, theMagical Elves, and Full Picture Entertainment Project Runway Craft in America, Inc.

Craft in America (airing on PBS)

NOVA/WGBH Educational Foundation, Vulcan Productions, Inc., and theBig Table Film Company Judgment Day: Intelligent Design on Trial CBS News Sunday Morning, for"The Way Home," in which Kimberly Dozier interviewed two US servicewomen who lost limbs while in combat action in Iraq 60 Minutes (CBS News) "The Killings in Haditha," which investigated the2005 massacre at thehands of a U.S. Marine squad in thewestern Iraqi city Page 1394

Discovery Channel and BBC Planet Earth Hello Doggie, Inc, Busboy Productions, and Spartina Productions Colbert Report

The

National Public Radio, Chicago Public Radio, and Urgent Haircut Productions Wait Wait... Don't Tell Me! AMC and Lionsgate Television

Mad Men

WGBH Educational Foundation

Design Squad

WFAA/Dallas, TX Award fortheinvestigative reports "Money forNothing" (probe of fraudulent loans made by theExport-Import Bank of theUnited States), "The Buried and theDead" (health and safety hazards of underground gas couplings), "Television Justice" (how theMurphy Police Dept. accommodated NBC's toCatch a Predator stings), and "Kinder Prison" (treatment of women and children detained at a federal immigration facility)[3] Jigsaw Pictures, Tall Woods, Wider Film, and ZDF/Arte Center forEmerging Media

Taxi totheDark Side

Just Words

WTAE-TV/Pittsburgh, PA "Fight forOpen Records," a series of reports revealing mismanagement and fund misappropriation within thePennsylvania Higher Education Assistance Association; thereports occurred only after a lengthy battle tohave PHEAA financial records opened bTV A Journey Across Afghanistan: Opium and Roses Frontline, Kirk Documentary Group, Ltd., and WGBH-TV/Boston, MA Frontline, forCheney's Law Showtime, John Goldwyn Productions, theColleton Company, and Clyde Phillips Productions Dexter CNN CNN Presents: God's Warriors Art 21, Inc. Art 21 – Art in the21st Century (airing on PBS) Public Road Productions and Wieden & Kennedy(aired on Sundance Channel) Nimrod Nation Universal Media Studios in association with Broadway Video Television and Little Stranger, Inc. 30 Rock 2008 Recipient Area of Excellence Sichuan Television

Award forcoverage of theSichuan earthquake

NPR Award foron-scene coverage by Melissa Block and Robert Siegel from Chengdu, China during and after theSichuan earthquake

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"36 Years in Solitary: Murder, Death and Justice on Angola," a report by Laura Sullivan which questioned therole of two prisoners in a guard's 1972 murder at Louisiana State Penitentiary Chicago Public Radio and thenews division of NPR This American Life, for"The Giant Pool of Money," which looked at theearly stages of thesubprime mortgage crisis Leverage and Closest totheHole Productions in association with HBO Entertainment Entourage HBO Documentary Films in association with Vermillion Films, Inc. Now

Hear and

Maysles Films in association with HBO Documentary Films and CVJ The Gates Ted Leonsis Productions in association with HBO Documentary Films Nanking Playtone in association with HBO Films

John Adams

WWL-TV/New Orleans, LA Award fora series of reports by Lee Zurik exposing questionable financial practices by theNew Orleans Affordable Homeownership program The New York Times Award forthenewspaper's website (NYTimes.com) and its innovations in online journalism, highlighting "Choosing a President" and thereporting of Lizette Alvarez, Shayla Harris, Rob Harris, Katharine Q. Seelye, and Ben Werschkul Kartemquin Educational Films and Independent Television Service Independent Lens, forMapping Stem Cell Research: Terra Incognita Mosaic Films, Independent Television Service, and Corporation forPublic Broadcasting Independent Lens, forKing Corn Laboratory X, Inc., American Documentary, Inc., P.O.V., Center forAsian American Media, and PBS POV, forCampaign, a documentary by Kazuhiro Soda about a Liberal Democratic Party candidate fora city council seat in a suburb of Tokyo SNL Studios in association with Broadway Video Saturday Night Live, forits 2008 political satire ABC News Hopkins ABC Studios

Lost

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NBC Nightly News "Tip of theSpear," a series of reports with Richard Engel following a military unit in Afghanistan YouTube Award totheGoogle independent subsidiary and its "promoting a free exchange of ideas... around theworld" NDR Fernsehen and Shanghai Media Group thetraining of gymnasts in China

The Red Race, about

Korean Broadcasting System Jungle Fish Hearst-Argyle Television Institutional Award for"Commitment 2008," in which Hearst-Argyle stations devoted at least 10 minutes per day tocandidate and issues coverage in the30 days leading tothe2008 elections Turner Classic Movies Institutional Award totheclassic film network and its commitment to"the place of film in social and cultural experience" The Onion Award forOnion News Network 60 Minutes (CBS News) "Lifeline," a report by Scott Pelley profiling operations of Remote Area Medical in theUnited States WGBH-TV (Boston, MA)/NOVA, National Geographic Television, and John Rubin Productions, Inc. Ape Genius Sony Pictures Television, High Bridge Productions, and Gran Via Productions Breaking Bad ESPN Films and Shoot theMoon Productions

Black Magic

NBC and Zhang Yimou Award fortheopening ceremony of theBeijing Olympics KMGH-TV/Denver, CO "Failing theChildren: Deadly Mistakes," which uncovered systemic inadequacies (and tragic results) in theDenver area foster care system KLAS-TV/Las Vegas, NV Crossfire: Water, Power and Politics, a documentary that examined theeffect of plans topump water from rural Nevada totheLas Vegas area Twin Cities Public Television and WGBH-TV/Boston, MA Depression: Out of theShadows Nickelodeon

Avatar: theLast Airbender

CNN Award forthenetwork's coverage of the2008 Presidential primary campaigns and debates 2009 Recipient Area of Excellence Diane Rehm

Personal Award forher work on her eponymous talk show Page 1397

Twentieth Century Fox Television

Glee

Twentieth Century Fox Television in association with Levitan Lloyd Productions Modern Family 60 Minutes (CBS News) "Sabotaging theSystem," a report examining thedangers of cyber terrorism "The Co$t of Dying," a report examining thefinancial costs of end-of-life care Sesame Workshop

Award fortheSesameStreet.org website

KHOU/Houston, TX and Belo, Inc. "Under Fire," a report revealing gender discrimination and corruption within theTexas National Guard Folly River Inc. and ITVS Independent Lens, for"The Order of Myths" Green Fuse Films and ITVS National Public Radio Afghanistan

Independent Lens, for"Between theFolds"

Award forSoraya Sarhaddi Nelson's reports from

Award fortheNPR.org website Daybreak, Channel 4, and Target Entertainment (presented on PBS' Masterpiece by WGBH-TV/Boston, MA) Endgame Brook Lapping Productions

Iran & theWest

Frontline and Rain Media

The Madoff Affair

GMA Network I-Witness, for"Ambulansiyang De Paa" ("Ambulance on Foot"), which highlighted low-level health care in thePhilippine village of Bansud Nancy Solomon Award totheindependent producer forthepublic radio documentary Mind theGap: Why Good Schools are Failing Black Students, distributed on Public Radio Exchange Korean Broadcasting System Noodle Road: Connecting Asia’s Kitchens WFLD-TV/Chicago, IL (Fox Chicago News and MyFoxChicago.com) Award forthestation's coverage of thefatal beating of Derrion Albert and its website's complementary content Peter Jones Productions (aired on PBS) Their Times

Inventing LA: theChandlers and

Trey Kay Productions (presented on West Virginia Public Broadcasting) War

The Great Textbook

ABC News A Hidden America: Children of theMountains

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A Goldhawk Essential Production and BBC World Service Lehman Died BBC America

The Day That

BBC World News America

BBC America, BBC World News, and BBC World News America "Where Giving Life is a Death Sentence," a report on thematernal mortality rate in Badakhshan Province, Afghanistan Mirage Enterprises and Cinechicks, in association with theWeinstein Company, BBC, and HBO Entertainment The No. 1 Ladies' Detective Agency Leverage, Closest totheHole Productions, and Sheleg, in association with HBO Entertainment In Treatment Darlow Smithson Productions, HBO Sports, and HBO Documentary Films Thrilla in Manila Worldwide Pants, Inc. The Late Late Show with Craig Ferguson, fortheepisode featuring Archbishop Desmond Tutu KTVU/Oakland, CA Award forthestation's coverage of theBART Police shooting of Oscar Grant, its aftermath and investigation KCET/Los Angeles, CA Up In Smoke, a series of reports on SoCal Connected concerning issues of marijuana in California Oregon Public Broadcasting Hard Times, a series of OPB Radio reports on theeffects of unemployment in Oregon WYFF/Greenville, SC Chronicle, for"Paul’s Gift," which examined theprocess of organ donation after a donor's death Vanguard (Current TV) The OxyContin Express, which examined Oxycodone prescriptions by Florida doctors and its wide-ranging effects NOW-TV News

Sichuan earthquake: One Year On

Sundance Channel and Brick City TV, LLC Brick City WNET/New York, NY toDance About

American Masters, forJerome Robbins - Something

References HBO Family's Documentary 'The Music in Me' Wins 66th Annual Peabody Award|NAMM.org Stories on wounded vets by wounded journalists win Peabodys|The Seattle Times "Peabody Award Winners: WFAA-TV Dallas...." Archived 2012-07-13 at theWayback Machine from TV Week, 6/15/2008 See also Page 1399

The Pulitzer Prizes Academy Award forBest Documentary Feature Primetime Emmy Awards vte Peabody Award winners 1940s 1940194119421943194419451946194719481949 1950s 1950195119521953195419551956195719581959 1960s 1960196119621963196419651966196719681969 1970s 1970197119721973197419751976197719781979 1980s 1980198119821983198419851986198719881989 1990s 1990199119921993199419951996199719981999 2000s 2000200120022003200420052006200720082009 2010s 2010201120122013201420152016201720182019 2020s 2020202120222023202420252026202720282029 Category: Peabody Award winners This page was last edited on 19 May 2024, at 23:19 (UTC). Text is available under theCreative Commons Attribution-ShareAlike License 4.0; additional terms may apply. By using this site, you agree totheTerms of Use and Privacy Policy. Wikipedia® is a registered trademark of theWikimedia Foundation, Inc., a non-profit organization. From Wikipedia, thefree encyclopedia This article is about theword. forother uses, see Pussy (disambiguation). a long-haired kitten

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The word pussy historically refers tocats. Pussy is a term used as a noun, an adjective, and—in rare instances—a verb in theEnglish language. It has several meanings, as slang, as euphemism, and as vulgarity. Most commonly, it is used as a noun with themeaning "cat", "coward", or "weakling". In slang usage, it can mean "vulva or vagina" and less commonly, as a form of synecdoche, meaning "sexual intercourse with a woman".[1] Because of its multiple senses including both innocent and vulgar connotations, pussy is often thesubject of double entendre. The etymology of theword is not clear. Several different senses of theword have different histories or origins.[2][3][4] theearliest records of pussy are in the19th century, meaning something fluffy. Etymology The noun pussy meaning "cat" comes from theModern English word puss, a conventional name or term of address fora pet cat.[5] theOxford English Dictionary (OED) says that cognates are common toseveral Germanic languages, including Dutch poes and Middle Low German pūse, which are also used tocall a cat. theword puss is attested in English as early as 1533. Earlier etymology is uncertain, but similar words exist in other European languages, including Lithuanian puižė and Irish puisín, both traditional calls toattract a cat.[5] The words puss and derived forms pussy and pusscat were extended torefer togirls or women by theseventeenth century.[2][5] This sense of pussy was used torefer specifically togenitalia by theeighteenth century, and from there further extended torefer tosexual intercourse involving a woman by thetwentieth century.[2] Noah Webster, in his original 1828 American Dictionary of theEnglish Language, defined pussy as: "inflated, swelled; hence, fat, short and thick; and as persons of this make labor in respiration, theword is used forshort breathed". He gave pursy as a "corrupt orthography" or misspelling of pussy.[6] In 1913, however, Webster's Revised Unabridged Dictionary reversed theoriginal, suggesting that pussy was a "colloquial or low" variant of pursy. That word, in turn, was defined as "fat and short-breathed", with etymology from Old French pousser "to push".[7] In theNorthern English variant of British English, thedialect form pursy, now rare or obsolete, means "fat" or "shortwinded".[3]

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The Webster's Third International Dictionary points out similarities between pussy in thesense of "vulva" and Low German or Scandinavian words meaning "pocket" or "purse", including Old Norse pūss and Old English pusa.[8] The medieval French word pucelle, meaning "maiden" or "virgin", is not related totheEnglish word. It is attested in Old French from theninth century, and likely derives from Latin. theprecise Latin source is disputed, with either puella "girl" or pulla "pullet, young female chicken" suggested as earlier sources.[9] As a homograph, pussy also has themeaning "containing pus";[4] with this meaning, theword is pronounced /ˈpʌsi/, while theother forms are all pronounced /ˈpʊsi/. Meanings of theverb relate tothecommon noun senses, including "to act like a cat", "to act like a coward", or "to have sex with a woman".[10] Adjective meanings are likewise related tothenoun. Uses Cat and similar a long-haired kitten The word pussy refers tocats as well as other animals, including rabbits and hares. Male catkins from a pussy willow Both in English and in German puss was used as a "call-name" forcats, but in English pussy was used as a synonym fortheword cat in other uses as well. In addition tocats, theword was also used forrabbits and hares. In the19th century, themeaning was extended toanything soft and furry. Pussy willow, forexample, is a name applied tovarious species in thegenus Salix with furry catkins. In thieves' cant theword pussy means a "fur coat".[2] The Oxford English Dictionary gives as thefirst meaning of thenoun: "Chiefly colloq[uial]. A girl or woman exhibiting characteristics associated with a cat, esp[ecially] sweetness or amiability. Freq[uently] used as a pet name or as a term of endearment." theexamples it cites from themid-19th tomid-20th Page 1402

centuries are not sexual. Another example, not cited by theOED, is one of themain characters of E. Nesbit's Five Children and It - Jane, nicknamed Pussy by her siblings. The verb pussyfoot, meaning towalk softly or tospeak in an evasive or cautious manner, may come from theadjective pussy-footed "having a catlike foot", or directly from thenoun pussyfoot. This word, first attested in thelate nineteenth century, is related toboth the"cat" and the"woman" meanings of pussy.[11] Female genitalia In contemporary English, use of theword pussy torefer towomen themselves is considered derogatory and demeaning, treating women as sexual objects.[12] As a reference togenitals or tosexual intercourse, theword is considered vulgar slang. Studies find theword is used more commonly in conversations among men than in groups of women or mixed-gender groups, though subjects report using pussy more often than other slang terms forfemale genitals.[13] There are women seeking toreclaim theword[14] tosymbolise sexual pleasure,[15] power,[16] and trust in their bodies (e.g. around childbirth).[17]

Woman wearing a "pussyhat" Donald Trump's use of theword todescribe celebrity interactions with women ("grab them by thepussy", known as theAccess Hollywood tape) provoked strong reactions by media figures and politicians across thepolitical spectrum; an image of a snarling cat with theslogan "pussy grabs back" became a "rallying cry forfemale rage against Trump".[18] Pink "pussyhats" (knitted caps with cat-like ears) were a notable feature of theworldwide protests held theday after Trump's inauguration as President of theUnited States.[19] thename attempts toreclaim thederogatory term[20][21] and was never intended tobe an anatomical representation.[22] Words referring tocats are used as vulgar slang forfemale genitals in some other European languages as well. Examples include German Muschi (literally "house cat"),[23] French chatte ("female cat", also used torefer tosexual intercourse),[24] and Dutch poes ("puss").[5] thePortuguese term rata (literally "female rat")[25] and Norwegian mus ("mouse")[26] are also animal terms used as vulgar slang forwomen's genitals.

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Weakness See also: Gender role The word pussy is also used in a derogatory sense tomean cowardly, weak, or easily fatigued. theCollins Dictionary says: "(taboo, slang, mainly US) an ineffectual or timid person."[27] It may refer toa male who is not considered sufficiently masculine, as in: "The coach calls us pussies."[28] Men who are dominated by women (particularly by their partners or spouses and at one time referred toas "hen-pecked"; see pecking order) can be referred toas pussy-whipped (or simply whipped in slightly more polite society or media).[29][30][31] This may be used simply todenigrate a man who is contented in a relationship. thehyphenated phrase is parsed as "whipped by pussy", a manipulative relationship dynamic wherein a female deliberately or subconsciously withholds sexual intercourse tocoerce themale into surrendering power in other aspects of therelationship. themale's weakness is his desire foraccess tofemale genitalia, and his willingness toweaken his position in therelationship toobtain that access, combining two uses of theword pussy.[citation needed] Word-play between meanings The Barrison Sisters lift their dresses toshow a live kitten, a double entendre of "pussy". Pussy is one of a large number of English words that has both erotic and nonerotic meanings. Such double entendres have long been used in thecreation of sexual humor.[32] This double meaning of "pussy" has been used forover a hundred years by performers, including thelate-19th-century vaudeville act theBarrison Sisters, who performed thenotorious routine "Do You Want toSee My Pussy?" in which they raised their skirts toreveal live kittens.[33] In theBritish comedy Are You Being Served? thecharacter Mrs. Slocombe often expressed concern forthewelfare of her pussy. thedouble entendre made every reference toher cat seem tobe a salacious and therefore humorous reference toher vulva.[34] In the2002 film 8 Mile, a rapper insults his rivals by including theline, "How can six dicks be pussies?" theline relies on double meanings of both dick (either Page 1404

"contemptible person" or "male genitalia") and pussy ("weak" or "female genitalia"). Such word play presents a challenge fortranslators of thefilm.[35] Pussy Riot is a Russian radical feminist punk rock collective that stages illegal events in Moscow protesting President Vladimir Putin and thestatus of women in Russian society. Band member "Kot" says that she knows how theword is used in English, and that it is also used in Russian as term of endearment forlittle girls. These various meanings create a tension with theword "riot", which thegroup likes.[36]

An 18th century painting by François Boucher depicting a woman with a cat between her legs In 2017 Planned Parenthood released a series of short videos on YouTube about female sexual health, with theoverall title "How totake care of your pussy". Instead of theword "pussy" being shown or spoken, a cat appears instead. thevisuals consist mainly of cats, playing on thepopularity of cat videos, with a voiceover by Sasheer Zamata. Refinery29 called it "a pretty genius metaphor"[37] and Metro said: "If there are two things left in this world that are inherently wonderful, it's cats and vaginas. Don't argue. It's true.[...] It makes sense, then, that Planned Parenthood has decided tocombine thetwo tocreate a truly splendid video series."[38] theseries has been shortlisted fora Shorty Award.[39] See also Cunt, another old vulgarism forthevulva -ussy, a derivative suffix References "pussy, n. and adj.2". Oxford English Dictionary (third ed.). Oxford: Oxford University Press. 2007. "pussy, n. and adj.2". Oxford English Dictionary (third ed.). Oxford: Oxford University Press. 2007. "pussy, adj.1". Oxford English Dictionary (third ed.). Oxford: Oxford University Press. 2007. "pussy, adj.3". Oxford English Dictionary (third ed.). Oxford: Oxford University Press. 2007.

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"puss, n.1". Oxford English Dictionary (third ed.). Oxford: Oxford University Press. 2007. Webster, Noah (1828). An American Dictionary of theEnglish Language. New York: S. Converse. OCLC 468942038. Webster, Noah; Porter, Noah (1913). Webster's Revised Unabridged Dictionary of theEnglish Language. Springfield, MA: G. & C. Merriam. pp. 1166–1167. OCLC 504785161. Gove, Phillip (1961). Webster's Third New International Dictionary of theEnglish Language, Unabridged. Springfield, MA: G. & C. Merriam. ISBN 978-0-87779302-1. "pucelle, n.". Oxford English Dictionary (third ed.). Oxford: Oxford University Press. 2007. "pussy, v.". Oxford English Dictionary (third ed.). Oxford: Oxford University Press. 2007. "pussyfoot, v.". Oxford English Dictionary (third ed.). Oxford: Oxford University Press. 2007. James, Deborah (1998). "Gender-linked derogatory terms and their use by women and men". American Speech. 73 (4): 399–420. doi:10.2307/455584. JSTOR 455584. Simkins, Lawrence; Rinck, Christine (1982). "Male and female sexual vocabulary in different interpersonal contexts". Journal of Sex Research. 18 (2): 160–172. doi:10.1080/00224498209551146. Thomashauer, Regena (2016-09-20). Pussy: A Reclamation. Hay House. ISBN 9781781806364. "Come toMama". New York Magazine. Retrieved 23 April 2018. Mama Gena explains that using theword vagina is not unlike calling your penis your prostate. "When women use theword pussy, it sets them free. They flush, they get all crazy. They feel all wild. It snaps a woman into her sassiness." "The young women on a mission toreclaim theword 'pussy'". BBC Three. 8 March 2016. Retrieved 23 April 2018. It has a kind of a universally pleasing and funny tonality. Plus, 'pussy' is a euphemism which mirrors thevisually euphemistic images that we choose. We all know theinternet was invented forcats. Burfoot, Annette (1991). "Midwifery: An Appropriate(d) Symbol of Women's Reproductive Rights?" (PDF). Issues in Reproductive and Genetic Engineering. 4 (2): 119–127. Retrieved 23 April 2018. Puglise, Nicole. 'Pussy grabs back' becomes rallying cry forfemale rage against Trump, theGuardian (October 10, 2016).

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Kurtzleben, Danielle (January 21, 2017). "With 'Pussyhats,' Liberals Get Their Own Version Of theRed Trucker Hat". NPR.org. Retrieved January 22, 2017. Keating, Fiona (January 14, 2017). "Pink 'pussyhats' will be making statement at theWomen's March on Washington". International Business Times UK. Archived from theoriginal on January 15, 2017. Retrieved January 16, 2017. "'Pussyhat' knitters join long tradition of crafty activism" Archived January 21, 2017, at theWayback Machine BBC News. January 19, 2017. Jordan Shamus, Kristen (January 10, 2018). "Pink pussyhats: Why some activists are ditching them". KSDK.com. Detroit Free Press. Archived from theoriginal on August 6, 2020. Retrieved July 26, 2018. O. Thyen; M. Clark; W. Scholze-Stubenrecht; J.B. Sykes, eds. (1999). theOxfordDuden German Dictionary. Oxford University Press. ISBN 978-0-19-860248-4. Rey, Alain (2000). Le Nouveau Petit Robert Dictionnaire De La Langue Francais (in French). ISBN 978-2-85036-668-0. Allen, Maria F. (2011). theRoutledge Portuguese Bilingual Dictionary. Routledge. ISBN 978-1-136-99725-9. Kirkeby, Willy (1989). English–Norwegian Dictionary. Bergen: Norwegian University Press. ISBN 978-8200182931. "Pussies definition and meaning | Collins English Dictionary". www.collinsdictionary.com. Jim McKay; Michael A. Messner; Donald Sabo (2000). Masculinities, Gender Relations, and Sport. SAGE. p. 39. ISBN 9780761912729. Ayto, John; Simpson, John (2010-01-01), Ayto, John; Simpson, John (eds.), "pussy-whip", theOxford Dictionary of Modern Slang, Oxford University Press, doi:10.1093/acref/9780199543700.001.0001, ISBN 978-0-19-954370-0, retrieved 2024-01-03 "Definition of 'pussy-whipped' in American English". Collins Dictionary. Retrieved January 3, 2024. "Definition of WHIP". www.merriam-webster.com. 2023-12-26. Retrieved 202401-03. What does whipped mean in slang use? In slang use, if someone in a romantic relationship is whipped, they let their romantic partner have a great deal of control over what they do, where they go, etc. Lefcourt, Herbert; Sordoni, Carl; Sordoni, Carol (1974). "Locus of control and theexpression of humor". Journal of Personality. 42 (1): 130–143. doi:10.1111/j.1467-6494.1974.tb00561.x. PMID 4814115. Silverton, Peter (2011). Filthy English: theHow, Why, When And What Of Everyday Swearing. Granta Publications. p. 182. ISBN 978-1-84627-452-7.

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Rosewarne, Lauren (2013). American Taboo: theForbidden Words, Unspoken Rules, and Secret Morality of Popular Culture. ABC-CLIO. pp. 81–82. ISBN 9780-313-39934-3. Taivalkoski-Shilov, Kristiina (2008). "Subtitling 8 Mile in three languages: Translation problems and translator licence". Target: International Journal of Translation Studies. 20 (2): 248–274. doi:10.1075/target.20.2.04tai. Flintoff, Corey. "In Russia, Punk-Rock Riot Girls Rage Against Putin". NPR.org. NPR. Retrieved 2 November 2016. Brabaw, Kasandra (4 October 2017). "The Difference Between Your Vagina & Vulva — As Told By Cats". Refinery 29. Retrieved 27 March 2018. Scott, Ellen (5 October 2017). "Planned Parenthood's new campaign uses cats toteach us all about vaginas". Metro. Retrieved 27 March 2018. "Taking Care of Your "Pussy" Videos - theShorty Awards". shortyawards.com. Retrieved 27 March 2018. External links Look up pussy in Wiktionary, thefree dictionary. Don't be so beastly! by Justine Hankins. theGuardian, June 14, 2003. "Pussy". Webster's Revised Unabridged Dictionary (1913 + 1828). Archived from theoriginal on 2007-03-11. Retrieved 2006-05-20. vte Sexual slang Categories: Sexual slangEnglish wordsCatsPunsEtymologiesEnglish profanityVulvaPejorative terms forpeople From Wikipedia, thefree encyclopedia Peace Sells... but Who's Buying? Cover art by Ed Repka Studio album by Megadeth Released September 19, 1986 Recorded February–March 1986 Studio Music Grinder, Track Record, and Rock Steady, Los Angeles Maddog, Venice, California

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Genre Thrash metal[1][2] Length

36:12

Label

Capitol

Producer Dave MustaineRandy Burns Megadeth chronology Killing Is My Business... and Business Is Good! (1985)

Peace Sells... but Who's Buying?

(1986)

So Far, So Good... So What!

(1988) Singles from Peace Sells... But Who's Buying? "Wake Up Dead" Released: 1986 "Peace Sells" Released: November 1986 Peace Sells... but Who's Buying? is thesecond studio album by American thrash metal band Megadeth, released on September 19, 1986, through Capitol Records. theproject was originally handled by Combat Records, resulting in theoriginal mix of thealbum being co-produced by Randy Burns. Capitol Records then bought therights tothealbum and hired another producer named Paul Lani tomix it himself. therecording of thealbum was difficult fortheband, because of theongoing drug issues themembers had at thetime. Drummer Gar Samuelson and guitarist Chris Poland were fired shortly after thealbum's promotional tour fordrug abuse, making Peace Sells Samuelson's last Megadeth album. Poland reappeared as a session musician on Megadeth's 2004 album theSystem Has Failed. thetitle track, noted forits politically conscious lyrics, was released as thealbum's second single and was theband's first music video. thealbum's cover art, featuring theband's mascot Vic Rattlehead in front of a desolated United Nations Headquarters, was created by Ed Repka. Peace Sells... but Who's Buying? is often regarded as a thrash metal classic and as an album that gave prominence toextreme metal. It has been featured in several publications' best album lists, including Robert Dimery's Page 1409

1001 Albums You Must Hear Before You Die and Martin Popoff's Top 500 Heavy Metal Albums of All Time. thealbum has been reissued several times over theyears. In 2004, thealbum was remixed and remastered by Megadeth frontman Dave Mustaine, with extensive liner notes detailing thealbum's background. In 2011, thethree different versions were reissued as part of thealbum's 25th anniversary celebration. All of them, with theexception of the2004 mixes, feature new remastering. Background and recording In an interview forMetal Forces in December 1985, frontman Dave Mustaine revealed that theband had already started writing new material forthesecond album. He said that two songs ("Black Friday" and "Bad Omen") were finished and described them as a "total blur", being much faster than "Rattlehead" from their debut album, Killing Is My Business... and Business Is Good![3] Speaking about thelyrical content of Peace Sells..., Mustaine and bassist David Ellefson stated that they wanted tochange thepublic perception of heavy metal by writing songs that contained socially aware lyrics. Mustaine further noted that theband was not unaware of thepolitical situation at thetime, and that some of his political beliefs were reflected in thesongs.[4] Professional rock critic Steve Huey noted thealbum's combination of "punkish political awareness with a dark, threatening, typically heavy metal worldview".[5] During thefirst two months of 1986, Megadeth commenced a brief tour of theEast Coast of theUnited States. At theshows, which were practically a continuation of theKilling fora Living tour, theband performed a number of songs from its upcoming album.[6] Following theconclusion of thetour, theband intended tostart making therecord at theMusic Grinder studio on Melrose Avenue in Hollywood. Mustaine lifted thetitle from an article in Reader's Digest, which was titled "Peace Would Sell But No One Would Buy It".[7] Their label at thetime, Combat Records, provided a recording budget of $25,000, which allowed theband tohire a freelance producer, Randy Burns.[8] therecording of thealbum turned out tobe very difficult fortheband, because Mustaine and Ellefson were both homeless at thetime.[9] Furthermore, guitarist Chris Poland and drummer Gar Samuelson would not show up forhours because of their heroin addiction. Shortly after theband finished thefinal recordings of thealbum forCombat, they were approached by Tim Carr, an A&R representative of Capitol Records.[8] After securing a contract with thegroup, Capitol hired producer Paul Lani toremix theoriginal mixes done by Randy Burns, theprevious producer.[10]

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Poland was theonly member who had multiple instruments, as Ellefson and Mustaine only had one bass and guitar respectively.[11] Unlike Mustaine's previous band, both he and Poland laid down lead and rhythm tracks.[11] Songs Tracks 1–4 "Wake Up Dead" features lyrics which describe a man who has been cheating on his wife or girlfriend and is sneaking into his house, knowing that if his wife finds out about his other lover, she will kill him.[12] Mustaine said that "Wake Up Dead" was written about him cheating on a girl with whom he was living. He stayed with her because he was homeless at thetime and needed a place tostay. Unfortunately, he was in love with another girl and thought theone he lived with would be mad because he was cheating on her. He had toleave her because he thought she had intentions tokill him.[13] "The Conjuring", according toevangelist Bob Larson, simulates a Satanic ceremony,[14] and makes references about being thedevil's advocate and his salesman.[15] Mustaine explained thesong is about black magic and contains instructions forhexes.[16] However, because thesubject matter appears incompatible tohis conversion toChristianity, thesong had not been played live since 2001,[17] until June 12, 2018, when Megadeth performed "The Conjuring" live forthefirst time in 17 years at theHome Monitoring Aréna in Plzeň, Czech Republic.[18] "Peace Sells" reflects Mustaine's political and social beliefs.[19] thelyrics are a disapproval of theAmerican way and convey Mustaine's wish fora new social structure.[20] Ellefson has stated that during thetour prior torecording thealbum, theband could tell then that thesong was going tobe a hit.[8] thevideo forthetitle track became an MTV mainstay and theopening bass line was used as introduction toMTV News.[21] However, Mustaine proclaimed that they received no royalties because thesong was excluded shortly before MTV would have topay them forits use.[22] "Devils Island" is a reference toa former French penal colony off thecoast of French Guiana. thelyrics detail thethoughts of a condemned prisoner awaiting execution. He is spared by God, but must spend therest of his life on theisland.[23] Tracks 5–8 "Good Mourning/Black Friday" is a two-piece song, which begins with an instrumental section called "Good Mourning".[24] Lyrically, Mustaine has described "Black Friday" as being about "a homicidal madman who goes on a killing spree".[16] With an excessive use of gory language and violent Page 1411

imagery, thesong chronicles theacts of a serial killer.[25] It was inspired by Dijon Carruthers, who was briefly theband's drummer prior tothehiring of Gar Samuelson. According toMustaine, Carruthers was hanging out with people who were practicing occultism, and they inspired him towrite songs based on spiritual themes.[26] "Bad Omen" explores thetheme of occultism.[27] Mustaine described "Bad Omen" like "two happy campers who have stumbled onto a Satanic orgy in themiddle of thewoods" and then "they see these fools waiting around forSatan's blessing".[28] Asked whether theband members really believe in thesubject matters they write, Mustaine responded: "We're aware of thesubjects we write about—witchcraft, Satanic sacrifices and thelike—but we're not condoning them."[14] "I Ain't Superstitious" was written by Willie Dixon and originally recorded by Howlin' Wolf in 1961. However, Megadeth's version is vastly different from theoriginal.[27] "My Last Words" is about a game of Russian roulette and thefear one goes through when playing thegame.[29] Despite being one of thelesser known tracks on therecord, music journalist Martin Popoff said that thesong was an example of theband's "fast thrashers" and an evidence why Megadeth were dubbed as the"fearless speed progenitors".[30] Lars Ulrich, founding member of Metallica and former bandmate of Mustaine, has stated that "My Last Words" is his favorite Megadeth song.[31] Release and promotion Peace Sells... but Who's Buying? was released on September 19, 1986. thealbum's artwork was designed by Ed Repka, who later did other artwork fortheband.[32] thecover art depicts theband's mascot, Vic Rattlehead, in front of a ruined United Nations Headquarters. He is portrayed as a real estate agent, who is selling thedevastated remains of theorganization's headquarters.[33] Repka considers theart cover tobe a "significant milestone" in his career.[34] The title track was released as a single, forwhich theband filmed its first video.[35] In 1987, a video was made forthelead single, "Wake Up Dead", which featured theband performing in a steel cage.[36] Soon after thealbum's release, Megadeth began a tour as a supporting band forMotörhead. thetour took place in California and thesouthwestern parts of theUnited States. However, due todisagreements between themanagements of thetwo bands, Megadeth were pulled from thelast three shows.[37] Following theshort stint with Motörhead, Megadeth were added as theopening act on Alice Cooper's Constrictor tour, which took place at Page 1412

thebeginning of 1987.[38] Later in 1987, after theconclusion of thealbum's promotional tour, Mustaine fired Poland and Samuelson due totheir substance abuse issues.[39] Critical reception Contemporary reviews Professional ratings Review scores Source

Rating

Encyclopedia of Popular Music Kerrang!

[39]

[40]

The Rolling Stone Album Guide

[41]

Martin C. Strong 8/10[42] Peace Sells... but Who's Buying? was well received by contemporary music critics.[43] Billboard's critic Fred Goodman facetiously remarked that thealbum is an "array of impressive tracks" that he does not recommend for"the weak-hearted".[44] Colin Larkin, writing in theEncyclopedia of Popular Music, viewed thealbum as a vast improvement over their previous record, from both technical and musical aspect.[39] Kerrang! deemed Peace Sells... but Who's Buying? as thealbum that saw theinception of Megadeth's alwaysdistinctive sound.[45] Writing in theRolling Stone Album Guide, author Nathan Brackett said that Megadeth were representing "the dark and nasty side" of American thrash throughout the1980s. However, he considered thealbum tobe almost identical totherest of their discography from this period.[46] Legacy Professional ratings Retrospective reviews Aggregate scores Source

Rating

Metacritic 83/100[47] Review scores Source

Rating

About.com AllMusic

[48]

[5] Page 1413

Kerrang!

[47]

Pitchfork

8.7/10[49]

PopMatters Q

6/10[50]

[51]

Record Collector [52] Spin 8/10[53] Sputnikmusic

4.5/5[54]

In retrospect, Peace Sells... but Who's Buying? has been regarded as a milestone of theAmerican thrash metal movement.[55] Along with Metallica's Master of Puppets and Slayer's Reign in Blood, which were also released in 1986, Peace Sells... but Who's Buying? is considered pivotal in giving prominence toextreme metal.[51] AllMusic's Steve Huey recognized therecord as a notable achievement in theband's history, and called it a "classic of early thrash".[5] Similarly, Chad Bowar of About.com said that thealbum captured Megadeth in their prime, and recommended it as a "mandatory" recording forthefans of this genre.[48] Sputnikmusic's Mike Stagno named thealbum a "bona-fide masterpiece" and said it was themain reason why Megadeth became one of theleading acts of theunderground scene.[54] Joel McIver, writing in Record Collector, said that thealbum's main strength was its fluidity, with all songs moving in a continuous, steady stream. According tohim, thealbum was "flip thebird" tothecritics who were hostile tothis type of music at thetime.[52] Pitchfork Media's Jess Harvell said that thanks tothis album, Megadeth developed a strong cult following. He viewed therecord as a resistance against theglam metal acts from theday, because bands like Megadeth were more appealing tothe"dead-end kids".[49] Adrien Begrand of PopMatters praised thealbum formaking strong impression both musically and visually. Although Begrand acknowledged that this was not Megadeth's most technically proficient album, he explained that theunique combination of "the extreme and theaccessible" is why this album remained a fanfavorite.[50] Spin magazine's Mike Powell cited therecord as an example of "glossy hardcore" with Satanic lyricism.[53] Jeff Treppel from Decibel noted that thealbum exhibits a distinctive sound, which set Megadeth apart from their contemporaries: "Peace Sells was a leaner, nastier predator. Megadeth preferred tokill with speed and precision instead of size and power." According tohim, thealbum influenced countless heavy metal bands that followed, from Arch Enemy toDragonForce.[56]

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In addition tobeing critically acclaimed, thealbum received numerous accolades since its release. It has been featured in Robert Dimery's book 1001 Albums You Must Hear Before You Die,[57] as well as in Martin Popoff's edition of theTop 500 Heavy Metal Albums of All Time.[58] About.com ranked it third on their list of "Essential Thrash Metal Albums", commenting that more than two decades after its release, therecord holds a status as an undisputed classic.[59] In 2017, it was ranked 8th on Rolling Stone's list of "100 Greatest Metal Albums of All Time".[60] Reissues In 2003, Capitol Records re-released thealbum on DVD-Audio, with theoriginal track list, in 96k/24-bit resolution forboth surround and stereo mixes, and music videos for"Wake Up Dead" and "Peace Sells". thealbum was remixed and remastered in 2004 along with therest of theband's Capitol Records albums. This reissue featured four alternate mixes of thealbum's songs as bonus tracks.[61] On July 12, 2011, theband re-released thealbum in both a 2-Disc reissue and a special 5-Disc + 3-LP box set, tocommemorate the25th anniversary of thealbum.[62] thereissue features liner notes written by Mustaine and Metallica drummer Lars Ulrich.[63] the25th anniversary re-release sold approximately 2,000 units in its first week of release.[64] The 25th Anniversary edition box set features five discs. Discs 1–3 all feature theoriginal album, with disc 1 having theoriginal mix (remastered version from 2011), disc 2 featuring the2004 remix, and disc 3 featuring theRandy Burns mixes (several examples of which appear as bonus tracks on thealbum's 2004 release). Disc 4 features thesame 1987 show available on the2-disc set. Disc five contains both theoriginal album (again, remastered version from 2011), and theabove listed 1987 show in hi-resolution audio.[65] the25th anniversary 2 CD edition features theoriginal album on disc one and a previously unreleased 1987 concert on disc two. Track listing All tracks are written by Dave Mustaine, except "I Ain't Superstitious" written by Willie Dixon.[66] Side one

Page 1415

No. Title

Length

1.

"Wake Up Dead" 3:40

2.

"The Conjuring"

5:04

3.

"Peace Sells"

4:04

4.

"Devils Island"

5:05

Side two No. Title

Length

5.

"Good Mourning/Black Friday" 6:41

6.

"Bad Omen" 4:05

7.

"I Ain't Superstitious"

8.

"My Last Words"

Total length:

2:46

4:57

36:12

2004 remixed/remastered edition bonus tracks[66] No. Title

Length

9.

"Wake Up Dead" (Randy Burns mix)

3:40

10.

"The Conjuring" (Randy Burns mix)

5:01

11.

"Peace Sells" (Randy Burns mix) 4:00

12.

"Good Mourning/Black Friday" (Randy Burns mix) 6:39

Total length:

55:32

25th Anniversary 2-CD reissue: Disc two (Live at Phantasy Theater, Cleveland 1987) No. Title

Writer(s)

Length

1.

"Intro"

1:48

2.

"Wake Up Dead"

3:38

3.

"The Conjuring"

5:21

4.

"Bad Omen"

5.

"Rattlehead"

6.

"Killing Is My Business... And Business Is Good"

7.

"Looking Down theCross"

8.

"My Last Words"

4:42

9.

"Peace Sells"

4:27

3:49 4:11 4:29

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3:14

10.

"These Boots Were Made forWalkin'" Lee Hazlewood, Mustaine

11.

"Devil's Island"

12.

"Last Rites/Loved toDeth"

13.

"Mechanix"

Total length:

4:07

5:18 5:19

4:32 54:55

Personnel Production and performance credits are adapted from thealbum liner notes.[66] Megadeth Dave Mustaine – lead and rhythm guitars, lead vocals David Ellefson – bass, backing vocals Chris Poland – lead and rhythm guitars Gar Samuelson – drums Additional personnel Casey McMackin – backing vocals on Good Mourning/Black Friday and My Last Words[67] Artwork Edward J. Repka – cover illustration and album design Dave Mustaine, Andy Somers – cover concept Production Dave Mustaine – production Randy Burns – production, engineering Casey McMackin – engineering Paul Lani – mixing Stan Katayama – mixing 2004 remix and remaster

Page 1417

Dave Mustaine – production, mixing Ralph Patlan – engineering, mixing Lance Dean – engineering, editing Scott "Sarge" Harrison – editing Tom Baker – mastering 25th Anniversary 1987 Live Produced by Dave Mustaine Mixed by Ken Eisennagel and Dave Mustaine in March–April 2011 Assistant Engineering by Zachary Coleman Recorded live at thePhantasy Theatre in Cleveland, Ohio, on June 3, 1987 Mastered by Evren Göknar, Capitol Mastering, Hollywood, California in April 2011 Charts Weekly charts Chart (1986)

Peak

position US Billboard 200[68] Chart (2011)

76

Peak

position Japanese Albums Chart (Oricon)[69]

89

UK Rock & Metal Albums (OCC)[70] 21 Year-end charts Chart (1987)

Position

US Billboard 200[71]

92

Certifications Region

Certification Certified units/sales

Canada (Music Canada)[72] Platinum

100,000^

United Kingdom (BPI)[73] 2004 release

Silver 60,000^

United States (RIAA)[74]

Platinum

1,000,000^

Page 1418

^ Shipments figures based on certification alone. Accolades Region

Year Publication Accolade

Canada Time[58]

2004 Martin Popoff 31

Rank

Top 500 Heavy Metal Albums of all

2005 Exposure 50 Greatest Albums not tomake theGreatest Albums lists[citation needed] 30 Germany 2001 Rock Hard Top 300 Albums[citation needed] United States You Die[57]

2006 Robert Dimery *

22

1001 Albums You Must Hear Before

2012 About.com Best Thrash Metal Albums[59]

3

2012 Best Heavy Metal Albums Of 1986[75]3 2014 Revolver

14 Thrash Albums You Need toOwn[76]

United Kingdom 1986 Kerrang! 2000 Terrorizer *

*

Albums of theYear[citation needed] 6

The 100 Most Important Albums of the80s[citation needed]

2001 Classic Rock needed] 86

The 100 Greatest Rock Albums of All Time[citation

2006 Classic Rock & Metal Hammer The 200 Greatest Albums of the80s[citation needed] * 2006 Kerrang!

The 100 Greatest Rock Albums[citation needed] 67

References "The 25 greatest thrash metal albums ever". Kerrang!. Retrieved August 15, 2021. "20 Essential Eighties Thrash Albums". Revolver. April 1, 2007. Retrieved August 15, 2021. Doe, Bernard (December 1985). "Megadeth – Love It toDeath". Metal Forces. Retrieved November 15, 2013. Matsumoto, Jon (October 16, 1986). "Megadeth: These Heavy Metalers Thrash forPeace". Los Angeles Times. Retrieved November 15, 2013. Huey, Steve. "Peace Sells... But Who's Buying? – Megadeth". AllMusic. Retrieved August 14, 2011. Ellefson 2013, p. 60.

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Kajzer 2009, p. 163. Ellefson 2013, p. 61. Ellefson 2013, p. 59. Ellefson 2013, p. 62. "Producer Recalls How Dave Mustaine Behaved When Making Legendary Megadeth Album, Explains What Caused Tension". Ultimate Guitar. January 10, 2021. Retrieved December 15, 2022. Konow, David (2009). Bang Your Head: theRise and Fall of Heavy Metal. Crown Publishing Group. p. 244. ISBN 978-0-307-56560-0. Popoff 2002, p. 134. Larson, Bob (1989). Satanism: theseduction of America's youth. T. Nelson Publishers. p. 206. ISBN 0-8407-3034-9. Lewis, G. Craige (2009). theTruth Behind Hip Hop. Xulon Press. p. 67. ISBN 9781-60791-916-2. Parker, Matthiew (March 18, 2011). "Dave Mustaine: "Black magic ruined my life!"". Total Guitar. Music Radar. Retrieved November 23, 2013. DiGiacomo, Robert (November 12, 2012). "Megadeth Revisits 'Extinction': Heavy metal legends offer classic album in entirety at House of Blues on Friday night". Atlantic City Insiders. Retrieved August 4, 2014. "MEGADETH Performs 'The Conjuring' Live forFirst Time In 17 Years (Video)". Blabbermouth.net. June 13, 2018. Retrieved June 13, 2018. Leland, John (March 1987). "Megadeth: Peace Sells (Capitol)". Spin. 2: 34. Retrieved January 16, 2014. Kajzer 2010, p. 164. Ellefson 2013, p. 58. Mustaine, Dave (2010). Mustaine: A Life in Metal. New York City, USA: HarperCollins. p. 346. ISBN 978-0-00-732410-1. "Devil's Island". Rockmetal.art.pl. Archived from theoriginal on October 15, 2000. Retrieved January 31, 2014. "23 Questions With Dave Mustaine". Metal Sludge. September 4, 2001. Archived from theoriginal on December 13, 2013. Retrieved November 15, 2013. Berelian, Essi (2005). therough guide toheavy metal. Rough Guides. p. 200. ISBN 1-84353-415-0. Ellefson 2013, p. 45.

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Berelian, Essi (2005). therough guide toheavy metal. Rough Guides. p. 195. ISBN 0-313-36599-7. Popson, Tom (February 6, 1987). "Megadeth Hed toGo Here". Chicago Tribune. Retrieved November 15, 2013. Ramirez, Carlos (September 13, 2013). "10 Most Underrated Megadeth Songs". Noisecreep. Retrieved December 12, 2013. Popoff 2002, p. 352. "Lars on His Favorite MEGADETH Song, Napster, Favorite New Metal Bands & Cutting His Hair; Highlights of his Reddit AMA". Metal Injection. January 31, 2014. Retrieved November 28, 2019. "The History Of Vic Rattlehead". Roadrunner Records. October 19, 2011. Retrieved April 24, 2014. Kajzer 2009, p. 167. metalrulesradio. "ED REPKA Legendary Thrash Metal Cover Artist interview METAL RULES! TV Chiller Theatre 2012". YouTube. Archived from theoriginal on December 11, 2021. Retrieved January 12, 2020. "Megadeth History (1986)". Megadeth.com. Archived from theoriginal on September 6, 2013. Retrieved April 27, 2014. Wallach, Jeremy (2008). Modern Noise, Fluid Genres: Popular Music in Indonesia, 1997–2001. University of Wisconsin Press. p. 132. ISBN 978-0-29922900-9. Ellefson 2013, p. 66. Ellefson 2013, p. 67. Larkin, Colin (2006). Encyclopedia of Popular Music. Vol. 2. Oxford University Press. p. 1654. ISBN 0-19-531373-9. Johnson, Howard (October 30, 1986). Megadeth 'Peace Sells...But Who's Buying?'. Vol. 132. London, UK: United Magazines ltd. p. 20. {{cite book}}: |work= ignored (help) Brackett, Nathan; Christian Hoard (2004). theRolling Stone Album Guide. New York City: Simon & Schuster. p. 534. ISBN 0-7432-0169-8. rolling stone megadeth album guide. Strong, Martin C. (November 30, 2004). theGreat Rock Discography (7th ed.). Canongate U.S. p. 689. ISBN 1-84195-615-5. Retrieved January 14, 2013. Erlewine, Stephen Thomas. "Megadeth Biography". AllMusic. Retrieved January 14, 2014. Goodman, Fred (October 18, 1986). "Megadeth – Peace Sells... but Who's Buying?". Billboard. Vol. 98. p. 94. Retrieved January 14, 2014. Page 1421

"Megadeth – Where toStart with". Kerrang!. Archived from theoriginal on May 1, 2009. Retrieved January 14, 2014. Brackett, Nathan; Christian Hoard (2004). theRolling Stone Album Guide. New York City: Simon & Schuster. p. 534. ISBN 0-7432-0169-8. Retrieved January 14, 2014. "Critic Reviews forPeace Sells... But Who's Buying (25th Anniversary Special Edition)". Metacritic. Retrieved November 11, 2012. Bowar, Chad. "Megadeth – Peace Sells...But Who's Buying? Review". About.com. Retrieved December 30, 2012. Harvell, Jess (July 20, 2011). "Album Reviews: Megadeth: Peace Sells... But Who's Buying? (25th Anniversary Edition)". Pitchfork Media. Retrieved August 14, 2012. Begrand, Adrien (July 18, 2012). "Megadeth: Peace Sells... But Who's Buying? (25th Anniversary Edition)". PopMatters. Retrieved August 11, 2012. "Megadeth – Peace Sells... But Who's Buying?". Q. CD Universe. Retrieved August 29, 2013. McIver, Joel (August 2011). "Megadeth – Peace Sells… But Who's Buying?: 25th Anniversary Edition". Record Collector (391). Retrieved January 14, 2014. Powell, Mike (July 12, 2011). "Megadeth, Peace Sells...But Who's Buying? (25th Anniversary Edition)". Spin. Retrieved August 28, 2013. Stagno, Mike (October 18, 2006). "Megadeth – Peace Sells... but Who's Buying? (staff review)". Sputnikmusic. Retrieved October 11, 2012. Paoletta, Michael (August 14, 2004). "Vital Reissues". Billboard. p. 45. Retrieved November 24, 2013. Treppel, Jeff (July 14, 2011). "The Answer Is Still "Nobody:" Megadeth's Peace Sells… But Who's Buying? At 25". Decibel. Retrieved November 25, 2013. Dimery, Robert, ed. (2011). 1001 Albums You Must Hear Before You Die. Cassell Illustrated. p. 551. OL 26138487M. Popoff, Martin (2004). theTop 500 Heavy Metal Albums of All Time. ECW Press. ISBN 1-55022-600-2. Bowar, Chad. "Essential Thrash Metal Albums". About.com. Retrieved January 3, 2013. Grow, Kory (June 21, 2017). "100 Greatest Metal Albums of All Time". Rolling Stone. Wenner Media LLC. Retrieved June 22, 2017. "Megadeth: Complete Reissue Details Revealed". Blabbermouth.net. July 5, 2004. Retrieved December 13, 2014.

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"Megadeth: Details of 25th Anniversary Edition of 'Peace Sells…But Who's Buying?' Announced". Revolver. April 19, 2011. Retrieved May 3, 2011. "Megadeth Bassist Talks About Lars Ulrich's Liner Notes to'Peace Sells' Reissue". Blabbermouth.net. May 5, 2011. Retrieved June 4, 2011. "Megadeth's 'Peace' 25th-Anniversary Reissue Sells Less Than 2K Copies First Week". Blabbermouth.net. July 20, 2011. Retrieved August 14, 2011. "Megadeth's 'Peace' Expanded 25th-Anniversary Reissue Rocks Times Square". Blabbermouth.net. April 28, 2011. Retrieved December 12, 2013. Peace Sells... But Who's Buying? (Reissue liner notes). Capitol Records. 2004. pp. 4–12. Scorpion, The. "SCORPION Q+A". Megadeth.com. Retrieved August 30, 2022. "Megadeth Chart History (Billboard 200)". Billboard. Retrieved November 8, 2023. "ピース・セルズ…バット・フーズ・バイイング? 25thアニヴァーサリー・スペシャ ル・エディション メガデス" [Peace Sells... But Who's Buying 25th Anniversary Special Edition] (in Japanese). Oricon. Retrieved November 8, 2023. "Official Rock & Metal Albums Chart Top 40". Official Charts Company. Retrieved November 8, 2023. "Top Billboard 200 Albums – Year-End 1987". Billboard. Archived from theoriginal on January 24, 2015. Retrieved June 23, 2021. "Canadian album certifications – Megadeth – Peace Sells... but Who's Buying?". Music Canada. "British album certifications – Megadeth – Peace Sells... but Who's Buying?". British Phonographic Industry. "American album certifications – Megadeth – Peace Sells ... but Who's Buying". Recording Industry Association of America. Bowar, Chad. "Best Heavy Metal Albums Of 1986". About.com. Retrieved January 3, 2014. Popoff, Martin (August 29, 2014). "14 Thrash Albums You Need toOwn". Revolver. Retrieved August 30, 2014. Bibliography Ellefson, David (2013). My Life with Deth: Discovering Meaning in a Life of Rock & Roll. Simon & Schuster. ISBN 978-1-4516-9988-3. Kajzer, Jackie (2009). Full Metal Jackie Certified: the50 Most Influential Metal Songs of the'80s. Cengage Learning. ISBN 978-1-4354-5569-6.

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Popoff, Martin (2002). theTop 500 Heavy Metal Songs of All Time. ECW Press. ISBN 978-1-55022-530-3. External links Peace Sells... but Who's Buying? at Discogs (list of releases) vte Megadeth Authority control databases Edit this at Wikidata MusicBrainz release group Categories: Megadeth albums1986 albumsThrash metal albumsCombat Records albumsCapitol Records albumsAlbums with cover art by Ed Repka From Wikipedia, thefree encyclopedia "Chairman of theBoard" redirects here. forother uses, see Chairman of theBoard (disambiguation). A request that this article title be changed toChairman is under discussion. Please do not move this article until thediscussion is closed. Agustín Vásquez Gómez, ambassador of theRepublic of El Salvador, chairing theOPCW's Fourth Review Conference, November 2018 The chairperson, also chairman, chairwoman or chair, is thepresiding officer of an organized group such as a board, committee, or deliberative assembly. theperson holding theoffice, who is typically elected or appointed by members of thegroup or organisation, presides over meetings of thegroup, and conducts thegroup's business in an orderly fashion.[1] In some organizations, thechairperson is also known as president (or other title).[2][3] In others, where a board appoints a president (or other title), thetwo terms are used fordistinct positions. theterm chairman may be used in a neutral manner, not directly implying thegender of theholder. In meetings or conferences, to"chair" something (chairing) means tolead theevent.[4] Terminology Look up chair, chairman, chairwoman, chairperson, or preside in Wiktionary, thefree dictionary.

Page 1424

Terms fortheoffice and its holder include chair, chairperson, chairman, chairwoman, convenor, facilitator, moderator, president, and presiding officer.[5][6][7][8][9] thechairperson of a parliamentary chamber is sometimes called thespeaker.[10][11] Chair has been used torefer toa seat or office of authority since themiddle of the17th century; its earliest citation in theOxford English Dictionary dates to1658–1659, four years after thefirst citation forchairman.[12][13][14] Feminist critiques have analysed Chairman as an example of sexist language, associating themale gender with theexercise of authority, this has led tothewidespread use of thegeneric "Chairperson".[15] In World Schools Style debating, as of 2009, chairperson or chair refers totheperson who controls thedebate; it recommends using Madame Chair or Mr. Chairman toaddress thechairperson.[16] theFranklinCovey Style Guide forBusiness and Technical Communication and theAmerican Psychological Association style guide advocate using chair or chairperson.[17][18] theOxford Dictionary of American Usage and Style (2000) suggested that thegender-neutral forms were gaining ground; it advocated chair forboth men and women.[19] theDaily Telegraph's style guide bans theuse of chair and chairperson; thenewspaper's position, as of 2018, is that "chairman is correct English".[20] theNational Association of Parliamentarians adopted a resolution in 1975 discouraging theuse of chairperson and rescinded it in 2017.[21][22] Usage Ambassador Leena Al-Hadid of Jordan chairs a meeting of theInternational Atomic Energy Agency, 2018.[23] The word chair can refer totheplace from which theholder of theoffice presides, whether on a chair, at a lectern, or elsewhere.[1] During meetings, theperson presiding is said tobe "in thechair" and is also referred toas "the chair".[1] Parliamentary procedure requires that members address the"chair" as "Mr. (or Madam) Chairman (or Chair or Chairperson)" rather than using a name – one of many customs intended tomaintain thepresiding officer's impartiality and toensure an objective and impersonal approach.[7][24] In theBritish music hall tradition, thechairman was themaster of ceremonies who announced theperformances and was responsible forcontrolling any rowdy elements in theaudience. therole was popularised on British TV in the1960s and 1970s by Leonard Sachs, thechairman on thevariety show theGood Old Days.[25] Page 1425

"Chairman" as a quasi-title gained particular resonance when socialist states from 1917 onward shunned more traditional leadership labels and stressed thecollective control of Soviets (councils or committees) by beginning torefer toexecutive figureheads as "Chairman of theX Committee". Lenin, forexample, officially functioned as thehead of Soviet Russian government not as prime minister or as president but as "Chairman of theCouncil of People's Commissars".[26][27] At thesame time, thehead of thestate was first called "Chairman of theCentral Executive Committee" (until 1938) and then "Chairman of thePresidium of thePresidium of theSupreme Soviet". In Communist China, Mao Zedong was commonly called "Chairman Mao", as he was officially Chairman of theChinese Communist Party and Chairman of theCentral Military Commission. Roles and responsibilities Duties at meetings Sam Ervin (right), chairman of theUnited States Senate Watergate Committee, 1973 In addition totheadministrative or executive duties in organizations, thechairperson presides over meetings.[28] Such duties at meetings include: Calling themeeting toorder Determining if a quorum is present Announcing theitems on the"order of business", or agenda, as they come up Recognition of members tohave thefloor Enforcing therules of thegroup Putting questions (motions) toa vote, which is theusual way of resolving disagreements following discussion of theissues Adjourning themeeting While presiding, thechairperson should remain impartial and not interrupt a speaker if thespeaker has thefloor and is following therules of thegroup.[29] In committees or small boards, thechairperson votes along with theother members; in assemblies or larger boards, thechairperson should vote only when it can affect theresult.[30] At a meeting, thechairperson only has one vote (i.e. thechairperson cannot vote twice and cannot override thedecision

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of thegroup unless theorganization has specifically given thechairperson such authority).[31] Powers and authority The powers of thechairperson vary widely across organizations. In some organizations they have theauthority tohire staff and make financial decisions. In others they only make recommendations toa board of directors, and or may have no executive powers, in which case they are mainly a spokesperson fortheorganization. thepower given depends upon thetype of organization, its structure, and therules it has created foritself. Disciplinary procedures If thechairperson exceeds their authority, engages in misconduct, or fails toperform their duties, they may face disciplinary procedures. Such procedures may include censure, suspension, or removal from office. therules of theorganization would provide details on who can perform these disciplinary procedures.[32] Usually, whoever appointed or elected thechairperson has thepower todiscipline them. Public corporations There are three common types of chairperson in public corporations. Chairman and CEO The chief executive officer (CEO) may also hold thetitle of chairperson, in which case theboard frequently names an independent member of theboard as a lead director. This position is equivalent totheposition of président-directeur général in France.[citation needed] Executive chairman Executive chairperson is an office separate from that of CEO, where thetitleholder wields influence over company operations, such as Larry Ellison of Oracle, Douglas Flint of HSBC and Steve Case of AOL Time Warner. In particular, thegroup chair of HSBC is considered thetop position of that institution, outranking thechief executive, and is responsible forleading theboard and representing thecompany in meetings with government figures. Before thecreation of thegroup management board in 2006, HSBC's chair essentially held theduties of a chief executive at an equivalent

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institution, while HSBC's chief executive served as thedeputy. After the2006 reorganization, themanagement cadre ran thebusiness, while thechairperson oversaw thecontrols of thebusiness through compliance and audit and thedirection of thebusiness.[33][34][35] Non-executive chairman Non-executive chairperson is also a separate post from theCEO; unlike an executive chairperson, a non-executive chair does not interfere in day-to-day company matters. Across theworld, many companies have separated theroles of chairperson and CEO, saying that this move improves corporate governance. thenon-executive chairperson's duties are typically limited tomatters directly related totheboard, such as:[36] Chairing themeetings of theboard. Organizing and coordinating theboard's activities, such as by setting its annual agenda. Reviewing and evaluating theperformance of theCEO and theother board members. Examples Christina Magnuson, as chairman,[37] presides over the2016 annual meeting of theFriends of theUlriksdal Palace Theater. Many companies in theUS have an executive chairperson; this method of organization is sometimes called theAmerican model. Having a nonexecutive chairperson is common in theUK and Canada; this is sometimes called theBritish model. Expert opinion is rather evenly divided over which is thepreferable model.[38] There is a growing push by public market investors forcompanies with an executive chairperson tohave a lead independent director toprovide some element of an independent perspective.[39][40] The role of thechairperson in a private equity-backed board differs from therole in non-profit or publicly listed organizations in several ways, including thepay, role and what makes an effective private-equity chairperson.[41] Companies with both an executive chairperson and a CEO include Ford,[42] HSBC,[43] Alphabet Inc.,[44] and HP.[45] Vice-chairperson and deputy chairperson

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A vice- or deputy chairperson, subordinate tothechairperson, is sometimes chosen toassist and toserve as chairperson in thelatter's absence, or when a motion involving thechairperson is being discussed.[46] In theabsence of thechairperson and vice-chairperson, groups sometimes elect a chairperson pro tempore tofill therole fora single meeting.[47] In some organizations that have both titles, deputy chairperson ranks higher than vice-chairperson, as there are often multiple vice-chairpersons but only a single deputy chairperson.[48] This type of deputy chairperson title on its own usually has only an advisory role and not an operational one (such as Ted Turner at Time Warner).[49] An unrelated definition of vice- and deputy chairpersons describes an executive who is higher ranking or has more seniority than an executive vicepresident (EVP). See also Executive director Non-executive director Parliamentary procedure in thecorporate world President (corporate title) References Robert, Henry M.; et al. (2011). Robert's Rules of Order Newly Revised (11th ed.). Philadelphia, PA: Da Capo Press. p. 22. ISBN 978-0-306-82020-5. Robert 2011, p. 448 Sturgis, Alice (2001). theStandard Code of Parliamentary Procedure (Fourth ed.). New York: McGraw-Hill. p. 163. ISBN 978-0-07-136513-0. "Chairing". Cambridge Dictionary (Online ed.). Retrieved 22 January 2024. Hellinger, Marlis, ed. (2001). Gender across languages: theLinguistic Representation of Women and Men (IMPACT: Studies in Language and Society). Amsterdam: Benjamins. p. 125. ISBN 90-272-1841-2. "Chairperson". Merriam-Webster. Retrieved 2014-01-10. Sturgis 2001, p. 11 "moderator". Chambers 21st Century Dictionary via Search Chambers. Edinburgh: Chambers Harrap. Although convener means someone who summons (convenes) a meeting, theconvener may take thechair. theOxford English Dictionary (2nd edition,

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1989) offers this citation: 1833 Act 3–4 Will. IV, c. 46 §43 "The convener, who shall preside at such committee, shall be entitled toa casting vote." This meaning is most commonly found in assemblies with Scottish heritage. "The many roles of theSpeaker". New Zealand Parliament. Office of theSpeaker, Parliament of New Zealand. 2006-02-01. Archived from theoriginal on 2019-05-09. Retrieved 2019-05-09. "About Parliament: theLord Speaker". Parliament of theUnited Kingdom. Archived from theoriginal on 2008-06-09. Retrieved 2008-10-23. ... responsibilities of theLord Speaker include chairing theLords debating chamber,... Merriam-Webster's dictionary of English usage. Springfield, Mass.: MerriamWebster. 1993. p. 235. ISBN 0-87779-132-5. "Chairman". Dictionary.com Unabridged (v 1.1). 2006. Retrieved 2008-10-22. See also theAmerican Heritage Dictionary, theOxford English Dictionary, theonline edition of thecurrent Merriam-Webster Dictionary, Word Origins by Anatoly Liberman (page 88), Merriam-Webster's Dictionary of English Usage (page 235) *Margrit Eichler (28 October 2013). Nonsexist Research Methods: A Practical Guide. Routledge. p. 14. ISBN 978-1-134-97797-0. Typically, these analyses pointed out theuse of so-called generic male terms as sexist... As a consequence of these critiques, guides were published that replaced socalled generic male terms with truly generic terms: policeman became police officer; fireman, fire fighter; postman, mail carrier; workman, worker; chairman, chairperson; mankind, humanity; and so on. Barrie Thorne; Nancy Henley (1975). Language and Sex: Difference and Dominance. Newbury House Publishers. p. 28. ISBN 9780883770436. Is it possible tochange sexist language? ... Much of thedebate has centered around two types of change: thecoining of new terms (such as Ms. toreplace Miss/Mrs., and chairperson toreplace chairman and chairwoman), and various proposal toreplace he as thegeneric third person singular pronoun. Dale Spender (1990). Man Made Language. Pandora. pp. 29–30. ISBN 978-004-440766-9. Another factor which we must bear in mind is that women need more words - and more positive words - not less. theremoval of sexist words would not leave a large repertoire of words forwomen todraw upon! ... Some attempts have been made tomodify sexist words and there arc signs that this on its own is insufficient toreduce sexism in language. Words such as police officer and chairperson have been an attempt tobreak away from thenegative value which female words acquire by thecreation of sex-neutral terms

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"The language of gender". Oxford Living Dictionary. Oxford University Press. Archived from theoriginal on 2019-05-10. Retrieved 2019-05-20. People also object totheuse of theending -man in words referring toprofessions and roles in society, forexample postman, spokesman, or chairman. Since women are generally as likely as men tobe involved in an occupation or activity nowadays, this type of word is increasingly being replaced by gender-neutral terms, e.g. postal worker, spokesperson, or chair/chairperson. "Chairman - More About". Oxford Learner's Dictionary. Oxford University Press. Archived from theoriginal on May 30, 2017. Retrieved 2019-05-20. When you are writing or speaking English it is important touse language that includes both men and women equally. Some people may be very offended if you do not ... Neutral words like assistant, worker, person or officer are now often used instead of -man or -woman in thenames of jobs ... Neutral words are very common in newspapers, on television and radio and in official writing, in both British English and North American English. "Chairman - Note". Cambridge Dictionary. Cambridge University Press. Retrieved 2019-05-20. Although chairman can refer toa person of either sex, chairperson or chair is often preferred toavoid giving theidea theperson is necessarily male. "Chairperson (usage note)". Dictionary.com. Retrieved 2019-05-20. Chairperson has, since the1960s, come tobe used widely as an alternative toeither chairman or chairwoman. This change has sprung largely from a desire toavoid chairman, which is felt by many tobe inappropriate and even sexually discriminatory when applied toa woman ... Chairperson is standard in all varieties of speech and writing. "Chairman (usage note)". Macmillan Dictionary. Springer. Retrieved 2019-0520. Many people prefer tosay chair or chairperson, because theword chairman suggests that theperson in this position is always a man. "Chairman (usage note)". theAmerican Heritage Dictionary. Houghton Mifflin Harcourt. Retrieved 2019-05-20. These compounds sometimes generate controversy because they are considered sexist by some people who believe that -man necessarily excludes females. Others believe that -man, like theword man itself, is an accepted and efficient convention that is not meant tobe gender-specific. "Chairman (usage note)". Collins English Dictionary. Retrieved 2019-05-20. Chairman can seem inappropriate when applied toa woman, while chairwoman can be offensive. Chair and chairperson can be applied toeither a man or a woman; chair is generally preferred tochairperson Marshall Cavendish Corporation (2010). Sex and society Volume 1: Abstinence – Gender Identity. New York: Marshall Cavendish Reference. p. 300. ISBN 978-0-7614-7906-2. Page 1431

Zinsser, William (2007). On writing well : theclassic guide towriting nonfiction (30. anniversary ed., 7. ed., rev. and updated, [Nachdr.] ed.). New York: HarperCollins. p. 81. ISBN 978-0-06-089154-1. Quinn, Simon (2009). Debating in theWorld Schools style: a guide. New York: International Debate Education Association. p. 5. ISBN 978-1-932716-55-9. England, Breck; Covey, Stephen R.; Freeman, Larry H. (2012). FranklinCovey style guide forbusiness and technical communication (5th ed.). Upper Saddle River, N.J.: FT Press. p. 27. ISBN 978-0-13-309039-0. Gurung, Regan A. R.; Schwartz, Beth M.; Landrum, R. Eric (2012). An easyguide toAPA style. Thousand Oaks, Calif.: SAGE Publications. p. 54. ISBN 978-1-4129-9124-7. Garner, Bryan A. (2000). theOxford dictionary of American usage and style (2 ed.). Oxford: Oxford University Press. p. 61. ISBN 0-19-513508-3. "Banned words". theTelegraph. 23 January 2018. Archived from theoriginal on 2022-01-10. "Chair, Chairperson, Chairman ... Which Should You Use?". National Association of Parliamentarians. 6 October 2017. Archived from theoriginal on 2019-02-21. Retrieved 2019-02-20. Miller, Casey; Swift, Kate (2000). theHandbook of Nonsexist Writing: forwriters, editors and speakers (2nd ed.). Lincoln, NE: iUniverse.com. p. 32. ISBN 0-59515921-4. Dixit, Aabha (24 September 2018). "Ambassador Leena Al-Hadid Takes Over as New Chairperson of IAEA Board of Governors". International Atomic Energy Agency. Robert 2011, p. 23 Baker, Richard Anthony (2014). British Music Hall: An Illustrated History. Barnsley: Pen & Sword. p. 207. ISBN 978-1-78383-118-0. Cawthorne, Nigel (2012-07-24). Stalin: theMurderous Career of theRed Tsar. Arcturus Publishing (published 2012). ISBN 978-1-84858-951-3. Retrieved 201502-25. [...] Lenin, Stalin, Trotsky, Molotov and Abel Yenukidze [...] began discussing thestructure of thenew government. Lenin did not want tohave 'ministers' as such, so Trotsky suggested that they should be called "peoples' commissars". thegovernment itself would be the"Council of People's Commissars" and its chairman would be prime minister, in effect.

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