Table of Contents

I. Introduction to Facility Coding Required Reading and Keywords Assignments References Flow of information within healthcare facility Processing, Filing and Storage of the Inpatient Medical Record Hospital Overview Types of Hospitals Departments within a Facility The Reimbursement Cycle Registration Department Information Gathering during Registration Tasks Associated with Registration Process Forms Associated with Registration Your Role in the Cycle Hospital Coders Roles and Responsibilities Coding Competencies Common Medical Billing and Collections Problems Standards of Ethical Coding Comparison of Law, Ethics & Moral Values Why Study Law and Ethics Coding Career Ladder Certified Coding Specialist (CCS) Professional Associations Qualities of a Successful Healthcare Practicioner Confidentiality and Patient Privacy Section I Test II. Healthcare Facility Medical Record and Documentation Required Reading Keywords Assignments References Introduction Definition of Medical Record Uniform Hospital Discharge data sets (UHDDS) Uniform Ambulatory Care data sets (UACDS) Use and Users of Data Documentation in the Medical Record History & Physical (H&P) Progress Notes Physician Orders Consents Operative Report Laboratory/Radiology Reports Graphics Record (Vital Signs) EKG (Electrocardiograph) Nurse's Notes Legalities of a Medical Record Guidelines for Documenting/Maintaining the Patient Health Record Retention of Medical Records III. Inpatient Facility Coding Guidelines Required Reading Keywords Assignments References Overview Coding Systems International Classification of Diseases, 10th Revision HCFA Common Procedural Coding (HCPCS) Current Procedural Terminology (CPT) Diagnosis Related Groups (DRG) Prospective Payment System (PPS) Ambulatory Patient Groups (APG) Diagnostic and Statistical Manual of Mental Disorders (DSM) IV. Outpatient Facility Coding Guidelines Required Reading Keywords Assignments References Using the Official Coding Guidelines Overview Textbook Usage Instructions Conventions, General Coding Guidelines Codes that describe a symptom or sign; B6-8 Multiple coding for a single condition: B-9 Acute and Chronic Conditions: B-10 Combination Codes: B-11 Late Effects: B-12 Impending or Threatened Conditions: B-13 Infectious and Parasitic Diseases Tuberculosis Septicemia And Bacteremia Gram-Negative Bacterial Infection AIDS/HIV Septicemia and Septic Shock Neoplasms 3 Steps for Coding Neoplasm Principal Diagnosis Selection for Neoplasms Diseases of Circulatory System Atherosclerosis Cerebrovascular Accident Myocardial Infarction Coronary Atherosclerosis Complications of Pregnancy, Childbirth, and the Puerperium Pregnancy , Delivery and Postpartum Late Effects Abortions Newborn (Perinatal) Guidelines Injury Fractures Burns E-Codes Poisoning, Adverse Reactions and Injury due to Drugs and Chemicals V-Codes Principal Diagnosis V. Outpatient Coding Guidelines Outpatient Facility Coding Objectives Table of Contents Required Reading - Keywords Assignments References The Outpatient Record Components and Order Outpatient Diagnostic Records Emergency Department Records Outpatient Surgery Records Overview of the Outpatient APC System / Other Outpatient Considerations Understanding the "72 hour" rule Observation Status Chargemaster Components of a Chargemaster Outpatient Prospective Payment System (OPPS) Using CPT-4 E&M Modifiers Surgery Additional references on CPT and Outpatient Coding VI. Preparing for the Certified Coding Specialist (CCS) Exam Intro Objectives Table of Contents Required Reading - Keywords Assignments References Procedure Coding with ICD-9-CM Volume III Diabetes Mellitus; ICD-9-CM Diagnosis System Specifics Anemia Mental Disorders Diseases of the Nervous System and Sense Organs Diseases of the Respiratory System Diseases of the Digestive System Diseases of the Genitourinary System Diseases of the Skin and Subcutaneous Tissue Progression of Lesion Excision with Closure Psychometrics, Measurements of the Mind Recall Application Analysis Examples of analysis Practice, Practice, Practice Additional Practice Assignments