- UPDATED Coding Clinic® citations provide official ICD-9-CM coding advice, ensuring accurate coding by identifying the year, quarter, and page number for information about specific codes in the AHA's Coding Clinic for ICD-9-CM. - UPDATED Exclusions and Present on Admission symbols ensure that you have the latest information needed for accurate coding. - UPDATED age edits from the Medicare Code Editor reflect the latest rules on checking diagnosis codes.
If you need to have a strong understanding of how ICD-9-CM diagnosis and procedure codes are determined, then you have chosen the right book, ICD-9-CM Inpatient Coding Reference and Study Guide. The author designed a book that goes beyond the fundamentals, that gets into the details of ICD-9-CM diagnosis and procedure code assignment as would be experienced on the job. This user-friendly reference teaches coders how to handle many coding situations, while also being comprehensive enough to teach someone with a basic knowledge of medical coding how to move to the next level of advanced inpatient coding. Updated every year to reflect the annual ICD-9-CM coding changes, the text enables HIM professionals to master the concepts of medical coding while also gaining critical knowledge to pass the CCS exam administered by AHIMA and the CPC-H exam from the AAPC. The book also serves as an excellent desk reference and resource for coders who need to refresh their ICD-9-CM coding skills. Among the topics covered in Volume 1 are inpatient coding guidelines, coding conventions, coding tables, and a drug reference. However, the heart of this manual is the body system analysis, based on chapters 1 - 17 of the Tabular list in Volume I of the ICD-9-CM Official Coding Guidelines. The chapters are categorized by body system such as respiratory, digestive, et al. The chapters in this study guide follow the same sequence as the Official Coding Guidelines. All chapters, in addition to highlighting basic coding guidelines, contain situation-based coding tips and coding examples. A quiz follows each chapter reinforcing concepts in a rigorous manner that applies directly to the professional coding environment. The book also contains a selective discussion of invasive procedures that the coder will most likely encounter on the job and on the exam. At the end of ICD-9-CM Inpatient Coding Reference and Study Guide are 15 case studies, providing the reader with an opportunity to assess their ICD-9-CM coding skill set and speed at coding inpatient medical records. Each record contains a face sheet, history & physical, progress notes, and answer sheet. Some of the case studies contain ER reports, consultations, as well as operative and pathology reports. The answer key at the end of this study guide contains a rationale for all code assignments. 456 short answer questions 116 multiple choice questions 15 full medical record case studies Each question is highly relevant and reflects a coding situation most hospital-based inpatient coders will face. The text strives to ensure the reader understands every diagnosis and procedure discussed: thorough discussion of symptoms, standard treatment protocols, and medications. Coding examples and quizzes help clarify the information presented. Linda Kobayashi, BA, RHIT, CCS, has been a coder and coding manager for almost 20 years. Since 1998, Ms. Kobayashi has owned and operated Codebusters, Inc., a nationwide coding consulting company. Widely regarded as a medical coding and auditing expert, she has conducted workshops on a variety of coding topics, including CCS Exam preparation workshops. Throughout her career the author has remained professionally active, as an AHIMA member as well as a member of her state association, CHIA (California health Information Association). Her formal training includes a teaching credential from California State University Los Angeles, a B.A. degree in English Literature from University of California Los Angeles, an RHIT from AHIMA after completing the RHIT program at East Los Angeles College, and a CCS certificate from AHIMA. Extensive experience as a hands-on coder, auditor and educator, and has given the author the expertise to help coders prepare for the professional coding environment.
Take your first step toward a successful career in medical coding with in-depth coverage from the most trusted name in coding education! Carol J. Buck's Step-by-Step Medical Coding, 2014 Edition is a practical, easy-to-use resource that shows you exactly how to code using all current coding systems. Explanations of coding concepts are followed by practice exercises to reinforce your understanding. In addition to coverage of reimbursement, ICD-9-CM, CPT, HCPCS, and inpatient coding, this edition provides complete coverage of the ICD-10-CM diagnosis coding system in preparation for the upcoming ICD-10 transition. No other text on the market so thoroughly covers all coding sets in one source! - Over 500 illustrations of medical procedures and conditions help you understand the services being coded. - Real-life coding reports simulate the reports you will encounter as a coder and help you apply coding principles to actual cases. - Complete coverage of ICD-10-CM prepares you for the upcoming transition to ICD-10. - Dual coding addresses the transition to ICD-10 by providing coding answers in both ICD-9 and ICD-10. - Official Guidelines for Coding and Reporting boxes allow you to read the official wording for inpatient and outpatient coding alongside in-text explanations. - From the Trenches, Coding Shots, Stop!, Caution!, Check This Out!, and CMS Rules boxes offer valuable, up-to-date tips and advice for working in today's medical coding field. - Exercises, Quick Checks, and Toolbox features reinforce coding rules and concepts, and emphasize key information. - Four coding question variations develop your coding ability and critical thinking skills. - Coder's Index makes it easy to quickly locate specific codes. - Updated content includes the latest coding information available, promoting accurate coding and success on the job. - New appendix with sample Electronic Health Record (EHR) screenshots provides examples similar to the EHRs you will encounter in the workplace.
These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.
Strengthen your ability to code accurately and obtain optimal reimbursement for medical services! Corresponding to the chapters in Carol J. Buck's Step-by-Step Medical Coding, 2014 Edition, this workbook offers review and practice with more than 1,500 questions, activities, and terminology exercises, and includes complete coverage of ICD-10-CM. It also includes over 90 original source documents to familiarize you with the reports you will encounter in practice. - Complete coverage of ICD-10-CM prepares you for the upcoming transition to ICD-10. - Dual coding addresses the transition to ICD-10 by providing coding answers in both ICD-9 and ICD-10. - Over 90 original source documents provide real-world experience with reports you will encounter in practice. - Workbook questions follow the same format as the text, including multiple code icons. - Theory, practice, and reporting exercises help you master key concepts and apply your knowledge. - Updated content includes the latest coding information available, promoting accurate coding and success on the job.
Elsevier and the American Medical Association have partnered to co-publish this HCPCS Level II reference by Carol J. Buck! For quick, accurate, and efficient coding, choose 2014 HCPCS Level II, Standard Edition! In an easy-to-use format, this practical reference presents the latest HCPCS codes to help you comply with coding regulations, confidently locate specific codes, manage supply reimbursement, report patient data, and more. - At-a-glance code listings highlight all new, revised, reinstated, and deleted codes for 2014. - Color-coded Table of Drugs makes it easy to find specific drug information. - Drug code annotations identify brand-name drugs as well as drugs that appear on the National Drug Class (NDC) directory and other FDA approved drugs. - Special coverage information provides alerts when codes have specific coverage instructions, are not covered or valid by Medicare, or may be paid at the carrier's discretion. - Jurisdiction information shows the appropriate contractor to be billed for suppliers submitting claims to Medicare contractors, Part B carriers, and Medicare Administrative Contractors submitting for DMEPOS services provided. - Codingupdates.com companion website includes HCPCS updates and corrections, and provides the opportunity to sign up for automatic e-mail notifications. - UPDATED codes help you maintain compliance with current Healthcare Common Procedure Coding System (HCPCS) standards.