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Codebusters™ Coding Connection: A Documentation Guide for Compliant Coding , Second Edition

Author(s): Patricia T. Aalseth, RHIA, CCS, CPHQ, Medical Coding And Documentation Consultant, Albuquerque, New Mexico
Details:
  • ISBN-13: 9780763726300
  • ISBN-10:0763726303
  • Spiral/paperback    424 pages      © 2005
Price: International Sales $80.95 US List
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Overview

Codebusters™ Coding Connection, Second Edition provides critical information that physicians, residents, medical students, and coders need for documentation to result in accurate and compliant coding. Revised to reflect changes in current payment systems, new national coding guidelines, and evolving medical terminology, this new edition includes these important updates:

  • The latest ICD-9-CM and CPT guidelines
  • Explains how language and terminology will change when ICD-10 is implemented
  • New coding categories for emerging diseases like SARS and West Nile virus 
  • New systems for outpatient coding
  • HIPAA mandated standardized code sets
  • New measures taken by OIG to ensure coding accuracy to combat fraud
  • Expanded diagnosis and procedure sections

With documentation rules and checklists for dozens of diagnosis and procedure categories, this book makes an ideal training tool and assists compliance officers in demonstrating that their institutions are following OIG guidelines. Its small size, inviting format, easy-to-read content and low price make it an invaluable resource for clinicians and coding/billing staff in all settings.

This book will help you:

  • Accurately code documents for dozens of diagnosis and procedure categories
  • Maximize reimbursement payments by accurately coding documents
  • Realize why being specific is essential to payable coding
  • Understand the implications of the transition to ICD-10-CM
  • Comply with important new coding guidelines

ShowKey Features

New to this Edition!

The second edition has been revised to incorporate updates on the following important issues:

  • The latest ICD-9-CM and CPT guidelines
  • Explains how language and terminology will change when ICD-10-CM and ICD-10-PCS are implemented
  • New coding categories for emerging diseases like SARS and West Nile virus 
  • New systems for outpatient coding
  • HIPAA mandated standardized code sets
  • New measures taken by OIG to ensure coding accuracy to combat fraud
  • Expanded diagnosis and procedure sections
     

Provides physicians with information to better understand the coding process and how coders work.

Gives specifics about the level of detail needed in documentation in order to assure accurate and complete coding.

Includes documentation rules and checklists for dozens of diagnosis and procedure categories.

The book’s emphasis on concepts and principles of coding as a basis for defining documentation requirements -- as opposed to specific code numbers -- prevents it from going out of date.

This book will help you:

  • Accurately code documents for dozens of diagnosis and procedure categories
  • Maximize reimbursement payments by accurately coding documents
  • Realize why being specific is essential to payable coding
  • Understand the implications of the transition to ICD-10-CM
  • Comply with important new coding guidelines

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ShowTable of Contents

Acknowledgements
Introduction

Chapter 1 - Introducing Coders

Coding professionals
How coders think
Coder resources
Coder challenges
The bottom line in coding

Chapter 2 - The Rules

Who makes the rules?
Who enforces the rules?
Who uses the two coding systems?
Basic ICD-9-CM rules
   Inpatient
   Outpatient / physician diagnosis
   Diagnosis coding
   Procedure coding
Basic CPT rules
   Procedure coding
Coding concepts
   Site
   Laterality
   Cause and effect
   Symptoms
 A Word about DRG’s and APC’s
 Observation
 V codes
 Rules for physician queries
 Why physicians are not the best coders

Chapter 3 - Diagnoses

How to use this section
Abdominal pain
Abortion
Alcohol use
Allergic reaction/adverse effect
   toxicity/overdose
Anemia
Angina
Arthritis
Asthma 
Back pain
Bites/stings
Breast cancer
Bronchitis
Burns
CAD/ASHD
Cardiac arrhythmias
Cardiomyopathy
Cataracts
Chest pain
CHF / pulmonary edema
Complications
Congenital / perinatal conditions
COPD
Cystocele/rectocele/prolapse
Dementia
Dermatitis
Diabetes
Drug abuse/addiction
Endometriosis
Fibroids
Follow-up
Fractures
Gastritis /ulcer
GI bleed
Glaucoma
Headache
Hemorrhoids
Hepatitis
Hernias
HIV
Hypertension
Hypo-/hyperthyroidism
Injuries
Mental disorders
Myocardial infarction
Neoplasms
Newborns
OB-Prenatal
OB-Delivery
Otitis
Pneumonia
Pre-op testing/screening
Renal insufficiency / failure
Septicemia vs. bacteremia
Stroke
Tuberculosis
UTI
Well patients

Chapter 4 – Procedures

How to use this section
Open vs. closed procedures
Eponymic procedures
Abortion
Amputation
Arthroplasty
Arthroscopy
Biopsies
Bladder suspension / colporrhaphy
Breast procedures
Bronchoscopy
Bunionectomy
CABG (Coronary Artery Bypass Graft)
Cardiac cath / PTCA / stent
Cataract removal
Chemotherapy
Colonoscopy / sigmoidoscopy
Cosmetic surgery
Cystoscopy / TURP / bladder tumors
Debridement
Destruction of skin lesions
EGD / esophagoscopy
Evaluation and management
Extraocular muscle procedures
Eyelid procedures
Fracture / dislocation treatment
Hardware removal
Hemorrhoidectomy
Hernia repair
Hysterectomy
Intestinal resection
Labor and delivery
Myringotomy / tympanoplasty
Osteopathic manipulative treatment
Pacemaker / AICD
Psychotherapy and assessment
Radiology – interventional
Retina procedures
Rhinoplasty / septoplasty
Sinus surgery
Skin grafts (free)
Skin grafts (flap)
Spine procedures
Tendon repair - hands
Thyroidectomy
Tongue procedures
Tonsillectomy / adenoidectomy
Varicose vein procedures
Vascular catheters
Wound repair

Appendix A - Excerpts from general inpatient
coding guidelines

Appendix B – Diagnostic coding and reporting
guidelines for outpatient services
(hospital-based and physician office)

Appendix C – ICD-9-CM coding for diagnostic tests

Appendix D – Modifiers

Appendix E – Data elements for general multi-system examination

Appendix F – E&M audit tool

Appendix G – ICD-10-PCS definitions of root operations

Appendix H – Standards of ethical coding


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ShowAbout the Author(s)

Patricia T. Aalseth, RHIA, CCS, CPHQ-Medical Coding And Documentation Consultant, Albuquerque, New Mexico

Patricia Aalseth, RHIA, CCS, CPHQ, has more than twenty-five years’ experience in health information management, focusing primarily on coding and documentation issues. She is currently Manager of Professional Billing for University Physician Associates at the University of New Mexico School of Medicine in Albuquerque.

Additional Titles by this Author

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