Abbreviations with Definitions and Explanations as They Pertain to Coding
Abbreviations are listed with explanations as they relate to the coders job. This will help coders better understand the various elements that affect reimbursement.
Advanced Practice Providers
In this action plan, coders learn the documentation requirements to bill for advanced practice providers such as NP, PA, CNM, CSW, CP and CNS.
AIDS and HIV Coding and Sequencing
The Official Coding Guidelines for Coding and Reporting and Coding Clinic advice will be reviewed as it relates to AIDS and HIV positive coding. The disease is explained along with treatments. Case scenarios are presented to aid the coder's understanding of code assignments and sequencing.
Anemia Overview- Types-Causes-Diagnosis and Treatment
This action plan provides a working knowledge of the pathophysiology, diagnosis and treatment of anemia to help the coder understand the condition and what to look for in the record in order to accurately assign the code and increase productivity.
Anesthesia
In the action plan, the coder learns what anesthesia services are, and how to code and bill for them.
APR-DRG System Introduction
In this action plan, coders will be introduced to the APR-DRG grouping system. The history and components of this complex grouping system will be explored and discussed. Severity of illness and risk of mortality will be explained and coding examples presented to show differences in levels and how they impact the relative weight, even if the APR-DRG is not impacted.
Arteriovenous Fistulas, Grafts and Graft Revision Coding in ICD-10-PCS
In this action plan, the coder willl learn the difference between an AV fistula and AV graft creation and proper root operations. Common diagnoses and procedures to correct these problems will be discussed in detail.
Arthrocentesis, Aspiration and Joint Injections
In this action plan, the coder learns how to code and bill for arthrocentesis, aspiration of joint and joint injections.
Bifurcation Qualifier Assignment in ICD-10-PCS Coding
In this action plan, coders will learn what to look for in assigning qualifier 6-Bifurcation for certain coronary artery procedures. Anatomy will be discussed as well as interpreting the operative report information. Case examples are utilized.
Biopsy Coding in ICD-10-PCS
In this action plan, we will explore the difficulties in coding biopsy procedures in ICD-10-PCS. Coders struggle with when to assign value “X” for “diagnostic” when tissue is biopsied. The difference between a diagnostic biopsy as an objective and routine biopsy of planned removed tissue will be explained in detail. Correct root operations for various biopsy procedures are discussed. Official coding guidelines will be reviewed. Case scenarios will be included in the quiz to test the student’s knowledge.
Biopsy Coding in ICD-10-PCS
This action plan will discuss various types of breast reconstruction, including implants and flap grafts, and how they are coded. Additional procedures that may be done as part of reconstruction revision will be included.
Bronchoscopy and Associated Procedures Coding in ICD-10-PCS
In this action plan, clinical and technical information related to bronchoscopic procedures will be viewed and discussed. The coder will learn how to maneuver troublesome coding areas in both the ICD-10-PCS. Bronchoscopy, transbronchial needle aspiration biopsies (TNBA), forceps biopsies and the difference between lung, bronchial tissue and lymph node tissue biopsy will be explored. All related coding guidance will be explained.
Bronchoscopy and Associated Procedures Coding in CPT
In this action plan, clinical and technical information related to bronchoscopic procedures will be viewed and discussed. The coder will learn how to maneuver troublesome coding areas in CPT coding. Bronchoscopy, transbronchial needle aspiration biopsies (TNBA), forceps biopsies and the difference between lung, bronchial tissue and lymph node tissue biopsy will be explored. All related coding guidance will be explained.
Bunion Procedure Coding in CPT
A bunionectomy is a common procedure for correcting a bony deformity on the side of the great toe. The difficulty for coders comes from the multitude of procedure variations. This action plan will give detailed descriptions of the most widely used bunion procedures and how they are coded in CPT. A bunion deformity at the base of the little toe, called a bunionette or tailor’s bunion, will not be discussed in this action plan.
Cardiac Arrest Coding and Sequencing
This action plan reviews the clinical aspects of cardiac arrest, causes and treatments. Official coding and sequencing advice is also presented to assist the coder in code assignment and sequencing.
Cardiac Catheterization Procedure Coding in ICD-10-PCS
In this action plan, clinical and technical information related to cardiac catheterization procedures will be discussed and reviewed. The coder will learn how to maneuver troublesome coding areas in ICD-10-PCS. The action plan will present how a cardiac catheterization is performed, what associated procedures are performed with the cardiac catheterization and how to accurately identify and code these procedures. All related coding guidance will be explained.
Cardiac Catheterization Procedure Coding in CPT
In this action plan, clinical and technical information related to cardiac catheterization procedures will be discussed and reviewed. The coder will learn how to maneuver troublesome coding areas in CPT. The action plan will present how a cardiac catheterization is performed, what associated diagnostic procedures are performed with the cardiac catheterization and how to accurately identify and code these procedures. All related coding guidance will be explained including the hierarchy format of the codes and the differences between normal and congenital cardiac catheterization codes.
Carotid Endarterectomy Coding in ICD-10-PCS
This action plan helps the coder to understand what carotid stenosis is, how it is addressed surgically, and the proper root operations and ICD-10-PCS codes to assign. This action plan includes videos and photos to help the coder understand the procedures and the anatomy involved. A sample operative note with code assignment is provided.
Cerebral Edema Overview: Types, Causes, Diagnosis, Treatment and Coding
This action plan provides a working knowledge of the causes and types of cerebral edema, pathophysiology, symptoms, diagnosis and treatments available. This will assist the coder in what to review in the medical record to accurately assign a code this diagnosis and increase productivity.
Cerebrovascular Accident, Infarction, Thrombosis, Embolus or Stroke and Sequelae Coding
This action plan will describe the clinical manifestations of an acute cerebral infarction/CVA/thrombosis/ embolus/stroke and common treatment modalities. Sequelae of cerebral infarction, etc. will also be discussed with an emphasis on when to assign the sequelae codes and when not to. Sequencing, especially involving principal diagnosis will be presented.
Cerumen Removal
In this action plan, the coder learns the nuances of coding and billing for the various types of cerumen removal.
Chronic Kidney Disease Coding
This action plan assists coders in assigning diagnosis codes for CKD and renal failure. Clinical information, symptomology and treatment are all included.
Coding Clinic Review to Improve Overall Code Accuracy
This action plan involves a Coding Clinic look up challenge to improve code assignment comprehension. It helps the coder realize the importance of utilizing official guidance for code assignment.
Colonoscopy Coding for Outpatients
This action plan is designed to help improve coding accuracy by enhancing a coder’s knowledge regarding the coding of diagnoses and CPT/HCPCS procedure codes for colonoscopies. The various problems in assigning correct codes for patients undergoing colonoscopies will be discussed along with solutions.
Colostomies- Creation and Takedown
This action plan is designed to help improve coding accuracy by enhancing a coder’s clinical knowledge about colostomies. Having a working knowledge of how a colostomy is formed and how the takedown procedure is accomplished may eliminate the need for extensive research or physician query.
Common Medications and the Conditions Treated
This action plan is designed to help the coder to improve their knowledge of commonly prescribed medications, which may in turn help to increase coding productivity. Special attention will be placed on cardiac and respiratory medications.
Complication of Transplanted Organ Coding
This action plan will address the complexities of diagnosis code assignment in patients who are of transplanted organ status. Official coding guidelines for complication coding along with other official advice will be presented and discussed. Clinical consideration, as well as sequencing dilemmas will be discussed. At the conclusion the coder will have a solid understanding of how to handle coding of patients with conditions associated with and not associated with a transplanted organ.
Congenital Disorder Diagnosis Coding
In this action plan, the difficulty in coding congenital disorders will be explained. Official Coding Guidelines for Coding and Reporting and Coding Clinic advice will be reviewed. Case scenarios are presented to aid the coder’s understanding.
Congenital Disorders Hypoplastic Left Heart Syndrome Diagnosis in ICD-10-CM
In this action plan, a detailed discussion is provided for the congenital condition of hypoplastic left heart syndrome. An overview of procedures related to this diagnosis will be covered. For more detail of these procedures, additional action plans are available. ICD-10-CM coding of this diagnosis will be discussed.
Congenital Disorders Hypoplastic Left Heart Syndrome Fontan Procedure in ICD-10-PCS
In this action plan, a detailed discussion is provided for the third stage palliative procedure done for hypoplastic left heart syndrome. For more detail on this diagnosis, see the action plan Congenital Disorders Hypoplastic Left Heart Syndrome Diagnosis in ICD-10-CM. ICD-10-PCS coding of the Fontan procedure will be covered.
Congenital Disorders Hypoplastic Left Heart Syndrome Norwood Procedure in ICD-10-PCS
In this action plan, a detailed discussion is provided for the first stage palliative procedure done for hypoplastic left heart syndrome. For more detail on this diagnosis, see the action plan Congenital Disorders Hypoplastic Left Heart Syndrome Diagnosis in ICD-10-CM. ICD-10-PCS coding of the Norwood procedure will be covered.
Congenital Disorders Hypoplastic Left Heart Syndrome Bidirectional Glenn Procedure in ICD-10-PCS
In this action plan, a detailed discussion is provided for the second stage palliative procedure done for hypoplastic left heart syndrome. For more detail on this diagnosis, see the action plan Congenital Disorders Hypoplastic Left Heart Syndrome Diagnosis in ICD-10-CM. ICD-10-PCS coding of the Bi-directional Glenn procedure will be covered.
Congenital Disorders Pulmonary Artery Stenosis and TOF Corrective Procedures in ICD-10-PCS
In this action plan pulmonary artery stenosis along with other defects diagnoses composing Tetralogy of Fallot (TOF) will be described clinically. The various procedures performed to correct pulmonary artery stenosis and other TOF defects will be explained in detailed. Proper procedure codes to include device selection and approaches are presented. The current diagnosis code vs a history of diagnosis code will be reviewed.
Congestive Heart Failure and Other Types of Heart Failure Coding
This action plan assists coders in assigning ICD codes for the different types of heart failure. Clinical information, types of heart failure, symptomology and treatment are reviewed. A quiz follows to test both clinical and coding knowledge.
Control of Bleeding Procedure Coding in ICD-10-PCS
In this action plan, the coder will learn when root operation "Control" and when other root operations are assigned in patients with acute or postprocedural bleeding. Official guidelines and coding advice is reviewed. Explanations are provided along with case examples. The quiz will assess the coder's knowledge using case scenarios.
Coronary Artery Bypass Graft Coding in ICD-10-PCS
In this action plan, the difficulties associated with “CABG” coding are discussed. The types of bypass grafts (LIMA, RIMA, aortocoronary, etc.), associated procedures and how to read a CABG op note to determine coding are presented. Official coding guidelines are included.
COVID-19 or Coronavirus Diagnosis Coding
In this action plan, diagnosis coding for the new COVID-19 (coronavirus) is explained. A description of COVID-19 is provided along with discussion of the new code created for use beginning with April 1, 2020 discharges. Case scenarios are used to explain different coding situations. A 10-question quiz follows.
Critical Care
In this action plan, the coder learns the definition of critical care, documentation requirements and how to code for these services.
Cystoscopy and Related Procedures CPT Coding
This action plan describes the cystoscopy procedure along with associated procedures performed at the time of cystoscopy. These include TURB, ureteral stent, and cutaneous urinary diversions for example. Anatomy of the urinary system and the actual procedures themselves will be discussed. Coding issues related to cystoscopy procedures including NCCI edits will be presented.
Debridement Coding in ICD-10-PCS
In this action plan, the coder will learn the different types of debridement and the documentation required by the physician in order to accurately assign a procedure code. Root operations and body part values are reviewed as they relate to debridement. A query example is included to help the coder formulate queries for debridement. This area is audited extensively by third party payers and CMS. It is crucial that correct coding and accurate documentation be present.
Documenting MDM
In this action plan, the coder learns the nuances of coding and billing for wound debridement for professional fee billing.
Dental D Codes Introduction
This action plan provides the coder with an introduction to assign “Dental Codes” otherwise known as “D Codes” from the CDT book by the ADA. Discussion of code composition, book section outline and details of several common D codes used in the outpatient surgery area are included. Two case studies are provided.
Diabetic Complications Coding in Patients with a Pancreas Transplant
This action plan specifically addresses the challenge of coding diabetic complications in patients who have had a pancreas transplant. The transplant can alter how these codes are reported. Clinical information and official coding guidance will be reviewed.
Documenting MDM
In this action plan, the coder learns how to correctly assess documentation and assign the Medical Decision Making component of the E and M code.
Drug Use, Abuse, Dependence and Associated Conditions Coding
This action plan specifically addresses the challenges of accurately coding drug use, drug abuse, drug dependence and associated conditions and situations. The action plan will address documentation as well as correct coding and sequencing.
Dry Needling vs. Acupuncture Professional Fee Coding
In this action plan, the coder learns the nuances of coding and billing for professional fee acupuncture vs dry needling. The differences between these two will be explained.
EGD with Endoscopic Ultrasound (EUS) CPT Coding
This action plan helps the coder to understand the EGD with EUS CPT codes and how they are assigned. The descriptors of the codes are very confusing as to what body parts the EGD involves, and what body parts the EUS involves. In addition, associated procedures such as FNA biopsy or injections add to the confusion. Each code is discussed step by step with videos and photos to help the coder understand the procedure and the anatomy involved.
EGD with Endoscopic Ultrasound (EUS) ICD-10-PCS Coding
This action plan helps the coder to understand the EGD with EUS ICD-10-PCS code assignment. Body part values for the stomach such as the antrum can be confusing and are presented in detail. The difference between tissue and drainage FNA are discussed. The confusion in assigning qualifier “X” for diagnostic in procedures where the objective is to biopsy is reviewed.
Electrophysiological Studies (EPS) and Ablation Coding in CPT
This action plan explains what electrophysiological studies (EPS) of the heart conduction system are and how various ablations are performed. The CPT coding is explained along with explanations of combination codes. The add on codes are also discussed.
Emergency Dept E&M
In this action plan, the coder will learn how to assign an emergency department professional fee E and M code. The pitfalls in coding these are reviewed.
Emergency Department CPT Procedure Coding
This action plan will focus on commonly reported CPT codes from the surgical section of the CPT manual. Procedures such as incision and drainage, nail procedures, laceration repairs, splinting/casting, burn treatments, closed fracture reduction, and foreign body removal will be reviewed. The use of modifiers will also be covered. Please keep in mind, this is only a portion of CPT codes that may be reported from Emergency Department records.
Endovascular AAA Endograft Procedures Coding in CPT
In this Action Plan the coder will learn about the various components of an endovascular AAA repair. Approaches, types of endografts and procedure detail will be discussed.
Endovascular Aortic Aneurysm Repair Coding in ICD-10-PCS
This action plan is designed to provide an overview of endovascular aortic aneurysm repair. Having a working knowledge of how the procedure is performed and the devices used may eliminate the need to do extensive research during the actual coding process. The coder will be able to make quicker decisions about the choice of procedure codes, or the need for a query just by understanding the basic procedure. This action plan will focus on an overview of endovascular repair of aortic aneurysms and some of the basic terminology used.
ERCP and Related Procedures Coding in CPT
This action plan helps the coder to understand the differing ERCP CPT codes and how they are assigned and what they actually include. ERCP procedure coding when multiple objectives are involved will be discussed. Official guidance is also presented. Each code is discussed with videos and photos to help the coder understand the procedure and the anatomy involved.
Evaluation & Management
This action plan provides a brief overview of the components of a professional fee evaluation and management code.
Excludes1 Note Interpretation
This action plan reviews how to properly follow the Excludes1 convention in ICD-10-CM. The differences between Excludes1 and Excludes2 are presented. Example and practice scenarios are discussed. Interim CMS advice on the Excludes1 note is provided.
External Cause ICD-10-CM Coding Misadventures and Adverse Incidents
In this action plan, the coder will learn the basics of external cause coding. Indexing, tabular and the different types of external causes are presented. The "IPAS" is discussed. After completing this action plan the coder can then take the other action plans on specific external cause topics.
External Cause ICD-10-CM Coding Transport Accidents
In this Action Plan, coders will learn how to index transport accident external cause codes and verify their choices. A 10 question quiz in which the question are open ended further enables the coder to test their comprehension. The coder inputs their answers via code numbers. The quiz will not count errors, however the correct explanation will be given after each question.
External Cause ICD-10-CM Coding Introduction
In this action plan, the coder will learn the basics of external cause coding. Indexing, tabular and the different types of external causes are presented. The "IPAS" is discussed. After completing this action plan the coder can then take the other action plans on specific external cause topics.
Global OB Package
In this action plan, the coder learns what the Global OB package is, what is included and excluded and how to bill.
Global Surgical Package
In this action plan, the coder learns the definition of global surgical package, what is included, excluded, and what to do when the physician furnishes less than the full global package.
Hemorrhagic Conversion Coding
In this action plan, coders will learn what a hemorrhagic conversion is in relation to CVA and cerebral infarction, and how to appropriately code different scenarios.
Hernia Repair Coding in ICD-10-PCS
This action plan will discuss the different types of hernias, hernia repairs, and how to code them. Techniques will be explained and root operation assignment discussed.
Hip Replacement Coding in CPT
In this action plan, coders will learn how to assign a CPT code for the various types of hip arthroplasty procedures. Total hip arthroplasty, hemiarthroplasty, revision of components and conversion to total hip arthroplasty will be explained. Anatomy, coding guidelines and requirements for coding these procedures are reviewed. Case examples are utilized.
Hip Replacement and IM Rod or Nail Coding in ICD-10-PCS
In this action plan, the coder will learn the fundamentals and key elements of coding total hip replacement, partial hip replacement/hemiarthroplasty, revision of hip arthroplasty, and intramedullary rod or nail insertion coding in ICD-10-PCS. Descriptions, photos and videos are utilized. Root operation, body part value, devices and official guidelines are presented and discussed. Practice scenarios are provided for the coder's education.
ICD-10-PCS Body Part Key Utilization
In this action plan, the coder will learn how to use the ICD-10-PCS Body Part Key to find obscure body parts that are not listed in the ICD-10-PCS tables. Scenarios are used to show the coder how to utilize the Body Part Key.
ICD-10-PCS Root Operations Review
This action plan will help the coder to review the root operations and their definitions primarily involving the Medical and Surgical Section of ICD-10-PCS. The reading assignment includes reading from the ICD-10-PCS Reference Manual and ICD 10 PCS Official Guidelines for Coding and Reporting. A 20 question quiz follows to test the coder’s knowledge of definitions.
Incident-To Services
In this action plan, incident to services are defined and explained. Place of service settings and coverage issues are also discussed.
Increasing Reading Speed
This action plan presents reading assignments to help the coder learn how to read more quickly and productively. Speed reading is included.
Injections and Infusions CPT Coding Part 1 - Introduction
In this Action Plan, the terminology, definitions and hierarchy of injection and infusion coding are presented and reviewed. The different types of injections and infusions are discussed clinically. Coding examples are used to present how to apply the injections and infusions hierarchy.
Injections and Infusions CPT Coding Part 2 - Coding Examples
Pre-requisite to this Action Plan is Injections and Infusions CPT Coding Part 1 - Introduction. In this action plan, coding scenarios based on the injections and infusions hierarchy are presented and explained. This will help the coder understand the hierarchy and code assignment in various injections and infusions situations.
Inpatient E&M Services
In this action plan, inpatient evaluation and management coding is described and defined. Coding pitfalls are presented.
Inpatient Neonatal and Pediatric Critical Care
In this action plan, inpatient neonatal and pediatric critical care is defined. Documentation requirements and proper code assignment are presented.
Interventional Radiology CPT Coding Introduction
This action plan reviews the basics of CPT Interventional Radiology (IR) coding. Vascular families and catheter selection coding are fully explained. Supervision and interpretation (S&I) codes are also discussed in brief. Examples are utilized to assist the coder in the understanding of code assignment. Use of CPT Professional Edition Appendix L is required for this Action Plan.
Inpatient & OBS Discharge Management
In this action plan, inpatient and observation discharge management is defined and the proper code assignment presented.
Introduction to CMS and Other Quality Measurement Programs and Relationship to Coding
This action plan will discuss the basics of various Quality Measurement programs such as: Value Based Purchasing (VBP); Inpatient Quality Reporting (Hospital IQR otherwise known as Core Measures); Hospital Acquired Conditions (HACs); Hospital Readmission Reduction Program (HRRP); Hospital Value Based Purchasing (HVBP); Hospital Acquired Conditions Reduction Program (HACRP); Agency for Healthcare Research and Quality (AHRQ) and Patient Safety Indicator Composite Group 30 (PSI 30) and; QualityNet.org. This action plan is meant only to be an introduction to quality measurement programs geared to the coder and will serve as a prerequisite to other more detailed and focused Action Plans on these subjects.
IPPS Changes for FY 2022
Discuss changes in IPPS for FY2022 effective October 1, 2021. Provide brief overall reimbursement update. Review new, deleted, revised DRGS and CC/MCCs. Review new, deleted and revised MCE edits. Discuss New Technology Payments and Provide List. Provide tables from the 2022 IPPS Final Rule
Knee Procedures CPT Coding Part 1- Anatomy and Common Surgical Terms
This action plan reviews key anatomy of the knee joint that is crucial to understand in order to assign knee procedure codes in CPT. Common surgical terms are reviewed and descriptions of surgeries provided along with informational photos and videos. This Action Plan is a prerequisite to Knee Procedures CPT Coding Part 2 – Understanding Code Reporting and Associated Edits.
Knee Procedures CPT Coding Part 2- Understanding Code Reporting and Associated Edits
This action plan explains the NCCI edits that affect multiple code reporting of knee CPT procedures. It is crucial for a coder to understand the NCCI edits and how they affect CPT coding and reporting. Modifiers are also discussed. Key coding challenges along with official coding guidance related to knee procedure CPT coding are presented.
Laceration Repair
In this action plan, the coder learns how to assign codes for laceration repairs for professional fee billing.
Laminotomy and Laminectomy Coding: Understanding CPT codes 63030 vs 63047
In this action plan, the difference between laminotomy and laminectomy CPT codes 63030 vs 63047 will be discussed. This is a confusing area for coders. Clinical descriptions and videos are used to help the coder understand the objective of each procedure and code to be assigned. Official references on the topic are presented.
Large Intestine Excision and Resection Coding in ICD-10-PCS
In this action plan, the coder will learn how to properly code various types of colon excisions and resections. The coder will learn the differences between excision vs resection of the colon, the individual body part values, and when to code to right or left hemicolectomy. Official guidelines concerning anastomosis of colon, biopsies and incidental excisions are discussed. The importance of proper approach value is also emphasized.
Locum Tenens
In this action plan, "Locum" Tenens" is defined and discussed. Documentation requirements are also presented.
Long Term Care Hospital (LTAC) Coding
In this action plan, the coder will learn how to properly choose a principal diagnosis and secondary diagnoses for patients admitted to Long Term Acute Hospitals, better known as LTACs. Sequencing can be difficult to discern when the patient is subacute and is being transferred to an LTAC. Official guidelines will be reviewed and scenarios presented. Procedure coding is touched upon. Upon completion the coder will have gained knowledge in choosing the principal diagnosis in LTAC cases.
Liver Disorders Coding and Sequencing
This Action Plan discusses the coding and sequencing of liver disorders such as Hepatic Encephalopathy, Cirrhosis, Hepatitis and liver failure. Problematic areas are addressed.
Lysis of Adhesions Coding in ICD-10-PCS
In this action plan, the coder will learn when and how to code for lysis of adhesions when performed with other procedures. Root operation, body part value, and official guidelines are presented and discussed. Practice scenarios are provided for the coder's education.
Malignant Neoplasm Coding: Current vs. History
In this action plan, the coder will learn when to assign a code for a current malignant neoplasm, and when to assign the history of malignant neoplasm code. Case scenarios are presented to help assist the coder's comprehension.
Mechanical Ventilation ICD-10-PCS Coding
A review of the rules of determining types of mechanical ventilation (invasive vs non-invasive), counting of duration and other issues that may be involved in coding procedures of patients receiving ventilation services are discussed in this action plan.
Medical Nutrition Therapy
In this action plan, medical nutritional therapy is defined and discussed. Documentation requirements and proper CPT code assignment is presented.
Modified Blalock-Taussing Shunt Procedure
In this action plan coders will learn why a Blalock-Taussig shunt is done, as well as how the procedure is performed. ICD-10-PCS coding of this procedure will be discussed.
Modifier 59 and X{EPSU} Assignment in CPT Coding
In this action plan, the NCCI edits will be reviewed. Common terms used will be explained. The coder will gain an understand of the edits and when and when not to assign additional CPT codes with modifier -59 in utilizing scenarios.
Modifier Assignment in CPT Coding - Hospital
This action plan reviews modifier assignment for CPT codes assigned by the hospital. The coder will learn about the differing modifiers and how they are used. Examples are used to help with understanding. Please note that modifier -59 and the X{EPSU} are not covered here. Please see the separate Action Plan named "Modifier 59 and XESPU} Assignment in CPT Coding."
Myocardial Infarction Part 1- Pathophysiology of Myocardial Infarctions
This action plan will examine the pathophysiology of a myocardial infarction and how they are classified according to the 2007 standardized definition.
Myocardial Infarction Part 2- Diagnosis and Treatment of Myocardial Infarctions
This action plan continues the discussion of myocardial infarctions. Emphasis is placed on the diagnostic tools available to the physician for the diagnosis of myocardial infarctions, as well as various treatment modalities.
Myocardial Infarction Part 3- Coding of Myocardial Infarctions
This action plan is designed to highlight the changes in coding of myocardial infarction using ICD-10-CM. Review of pertinent guidelines and Coding Clinics will be presented.
Neoplasm Coding in ICD-10-CM Introduction
In this action plan, the coder will learn what a neoplasm is, the different types of neoplasms and how to correctly index and assign diagnosis codes for the various neoplasms. Official Guidelines for Coding and Reporting regarding proper sequencing of primary and secondary sites will be reviewed.
Nephrostomy, Nephroureteral Stent and Nephrolithotomy CPT Coding
In this action plan, learn the differences between the different types of catheters and stents, such as percutaneous nephrostomy, internal ureteral and nephroureteral. Many times, the types of catheters or stents placed can be confusing due to lack of documentation and descriptions. This action plan describes each catheter or stent and explains how each are coded for insertion, removal or replacement. The differences between the stents or catheters is emphasized. Photos help to show the differences. Percutaneous nephrolithotomy is also described, along with the codes for percutaneous dilation of tract.
Neurostimulation (Intracranial) Coding in CPT
This action plan will discuss the different types of intracranial neurostimulation (neuromodulation) (neurostimulators) and how the implantation, removal or revision of the devices would be coded in CPT. The device components are described in detail. Photos and a video are used to help the coder understand these devices and procedures. Separate action plans are available for discussion of spinal and peripheral neurostimulation.
Neurostimulation (Spinal) Coding in CPT
This action plan will discuss the different types of spinal cord neurostimulation (neuromodulation) and how the implantation, removal or revision of the devices would be coded in CPT. The device components are described in detail. Photos and a video are used to help the coder understand these devices and procedures. Separate action plans are available for discussion of intracranial and peripheral neurostimulation.
New CPT Codes and HOPPS Changes for CY2022
In this session the new, deleted and revised surgical CPT codes for CY2022 will be presented. A brief overview of E&M changes is provided. Photos and videos are used to help the student understand the changes. Any changes to the HOPPS system will be discussed. A 20 question quiz follows.
New and Established Patients
In this action plan, the coder will learn the difference between new and established patients. Definitions are presented and explored.
New ICD 10 CM Diagnosis Codes and Changes FY 2022- AHIMA and AAPC
Review new, deleted, revised ICD-10-CM diagnosis codes effective October 1, 2021 for FY2022. Review significant changes from clinical perspective in some areas. Discuss reasons behind changes and updates to the ICD-10-CM Official Guidelines for Coding and Reporting.
New ICD 10 PCS Procedure Codes and Changes FY 2022 - AHIMA Only
Review new, deleted, revised ICD-10-PCS procedure codes effective October 1, 2021 for FY2022. Review significant changes from clinical perspective in some areas. Discuss updates to the ICD-10-PCS Official Guidelines for Coding and Reporting and use examples where applicable to further explain the changes.
New CPT Codes and HOPPS Changes CY 2022 AAPC and AHIMA
In this session the new, deleted and revised surgical CPT codes for CY2022 will be presented. A brief overview of E&M changes is provided. Photos and videos are used to help the student understand the changes. Any changes to the HOPPS system will be discussed. A 20 question quiz follows.
Newborn Secondary Diagnosis Coding and Reporting
This action plan specifically addresses the coding and reporting of newborn and neonatal secondary diagnoses. The coder will learn when to report and when not to report secondary neonatal diagnoses.
Nuss vs Ravitch Procedure for Pectus Ecavatum Coding in ICD-10-PCS
In this Action Plan, the Nuss and Ravitch procedures, performed to correct pectus evacatum will be discussed. Procedural information about the objective and thus the root operation of these procedures is presented. Scenarios and videos are used to help the coder comprehend these procedures.
Observation to Inpatient Status Diagnosis Coding
This action plan will address the complexities of clinical documentation and diagnosis code assignment in patients who are admitted to observation status and then transferred to inpatient status. The importance of correct physician orders and correct principal diagnosis selection we be addressed. This area is a frequent cause of MS-DRG assignment errors. Official advice in this area will also be reviewed.
Obstetrics Principal Diagnosis Selection and Coding
This action plan focuses on how to select the correct principal diagnosis on Obstetric/Pregnancy cases. Official Guidelines for Coding and Reporting and other advice is addressed with commentary and practice cases.
Obstetrics ICD-10-CM Coding Cord Entanglement and Group B Strep
In this action plan, coders will learn what to look for in assigning the obstetric codes for cord entanglement and group B strep. Coders struggle with these two obstetrics topics.
Obstetrics ICD-10-PCS Procedure Coding
Official coding guidelines, correct coding information and descriptions of procedures involving obstetrical and pregnancy cases will be discussed in depth in this action plan. Coders will know when and how to report which procedure codes for various obstetrical procedures
Obstetrics Secondary Diagnosis Coding
In this action plan, the importance of coding and reporting obstetrics secondary diagnoses will be reviewed. Deciphering proper 7th characters in situations where the patient has antepartum, delivery and postpartum related conditions will be explored via official coding guidelines and references.
Obstetrics Principal Diagnosis Practice Scenarios (Prereq: Obstetrics Principal Diagnosis Selection and Coding)
*Prerequisite is “Obstetrics Principal Diagnosis Selection” In this Action Plan practice scenarios are presented to teach the coder how to correctly assign the principal diagnosis involving obstetrical and pregnancy cases. Emphasis is placed on “labor and delivery complicated by” and “pregnancy complicated by” differences.
Occupational Therapy
In this action plan, the coder learns what occupational therapy is and how it is coded. Documentation requirements and performance deficits are presented.
Osteopathic Manipulative Treatment
In this action plan, osteopathic manipulation is defined and described. Proper documentation and code reporting is presented.
Outpatient Encounters First Listed or Primary Diagnosis Assignment
This action plan explains how to select the "first listed" or "primary" diagnosis on outpatient encounters to include ancillary, emergency room, clinic and outpatient surgery visits. Although both facility coding and professional fee coding and billing are discussed, the emphasis will be on facility coding and reporting. The official coding guidelines for outpatient reporting will be reviewed along with CMS transmittals addressing this topic.
Pacemaker Procedure Coding in ICD-10-PCS
In this action plan, the correct coding of pacemaker generators along with proper ICD-10-PCS coding of lead insertion will be presented. Videos and photos are utilized to teach the coder about the different types of pacemakers and defibrillators. Coding of revisions and upgrades are also presented.
Pain Management Coding and Sequencing
This action plan is a refresher in pain management coding with exercises on coding and sequencing guidelines as they pertain to pain management.
Pancytopenia and Neutropenia Coding
This action plan will address the complexities of clinical documentation and diagnosis code assignment in patients who are diagnosed with pancytopenia or neutropenia. Official coding guidelines along with other official advice such as Coding Clinic will be presented and discussed. Clinical consideration, as well as sequencing dilemmas will be presented. At the conclusion the coder will have a solid understanding of how to handle coding of patients diagnosed with pancytopenia and/or neutropenia.
Patient Discharge Status or Patient Disposition Assignment
In this action plan, the coder will learn the importance of correct patient status codes, formerly called disposition codes. The coder will learn each of the patient status codes and how they are used. Explanation of how reimbursement is affected through PACT and special pay DRGS is also explained. Common patient status errors are provided. The quiz will assess the coder's knowledge of the action plan material.
Patient Safety Indicator 15 (PSI 15) Unrecognized Abdominopelvic Accidental Puncture or Laceration Rate
This action plan will discuss AHRQ’s PSI 15, Unrecognized Abdominopelvic Accidental Puncture or Laceration Rate. The actual indicator itself will be explored and it’s relation to the coding and reporting of accidental lacerations occurring during abdominopelvic surgery. The controversial issues along with official coding guidance will be explored utilizing coding scenarios.
Percutaneous Vascular Stent and Angioplasty- Non Lower Extremity and Non Intracranial CPT Coding
This action plan provides a review of angioplasty and stenting procedures. Interventional radiology procedure guidelines and various coding dilemmas are presented as they pertain to CPT coding. Provides the coder with a working knowledge of when and when not to assign a CPT code for an angioplasty.
Pharm-D Incident-To
In this action plan, Pham.D Incident to services are defined and discussed. Documentation requirements are presented.
Physical Therapy
In this action plan, physical therapy documentation requirements and coding guidelines are presented and discussed. Modifier use and therapy cap are also presented.
Place of Service Codes
In this action plan, place of service codes are defined and their use on professional claims are presented.
Pneumonia Coding - Types, Causes, Diagnosis and Treatment
A review of pneumonia types, clinical indicators, causes and treatments are presented to the coder. Pneumonia code assignment and sequencing guidelines are reviewed.
Point of Origin (POO) Reporting
In this action plan, coders will learn the importance of reporting the correct point of origin, formerly called "admission source." The selections will be described. Common review errors are included.
Postoperative Complication Coding
This action plan will explore the dilemma of coding and reporting postoperative complication codes based on physician documentation. The difference between expected postoperative conditions and true intraoperative or postoperative complications will be presented. Coding scenarios are provided for understanding.
Present on Admission Reporting Guidelines
The objective of this action plan is to ensure appropriate POA indicators are assigned. This will assist the coder in deciding if a diagnosis or condition is present on admission
Primary Care Exception Billing
In this action plan, the primary care exception is defined, and requirements explained.
Principal Diagnosis Assignment
The selection of principal diagnosis guidelines are presented in this action plan. Documentation scenarios are presented to teach the coder how to select the correct principal diagnosis.
Principal Diagnosis Selection: Acute versus Chronic Underlying Conditions
This action plan specifically addresses selection of the principal diagnosis when the patient is admitted with an acute condition due to a documented underlying cause.
Principal Diagnosis Selection: When Two Diagnoses Qualify
This action plan is composed of exercises to help select the appropriate PDX when two conditions may equally apply.
Principal Diagnosis Selection: Symptom Code vs Diagnosis Code as Principal Diagnosis
This action plan specifically addresses selection of principal diagnosis when the patient is admitted with a symptom and another diagnosis. Coding rules related to the sequencing of these cases is presented.
Principal or Primary ICD-10-PCS Procedure Code Selection
In this action plan, UHDDS, Official Guidelines for Coding and Reporting, and Coding Clinic references are discussed in regards to selecting the principal or primary ICD-10-PCS procedure. Coders will learn how to accurately select a principal or primary procedure, and what to do when multiple procedures are present and no definitive procedure has been performed for the principal diagnosis.
Prolonged Services (Professional Fee)
In this action plan, the coder learns how to correctly assign prolonged services CPT codes given the updates effective January 1, 2022.
Psychiatric Diagnosis Coding
This action plan assists coders in proper sequencing and assignment of psychiatric diagnosis codes in ICD-10-CM for acute care inpatient hospitals. The reasons for sequencing will be discussed. Case examples with explanations are provided.
Psychotherapy
In this action plan, psychotherapy codes are defined and requirements discussed.
Reading and Understanding Operative Reports
This action plan is designed to help coders improve their ability to comprehend and accurately code from an operative report, which may in turn help to increase coding productivity.
Rehabilitation Coding for the Hospital UB-04 and the IRF-PAI
This action plan will review the official guidance on how to select a principal diagnosis for hospital UB04 coding. Difficulties associated with selecting a principal diagnosis since an equivalent code to V57.- is not available in ICD-10-CM will be discussed. MS-DRG impact from this decision is presented. The differences between hospital UB-04 rehabilitation coding and Rehabilitation Unit IRF-PAI diagnosis coding will be reviewed.
Respiratory Failure-Causes-Clinical Information-Treatment- and Coding Conventions
This action plan reviews the clinical aspects of respiratory failure, respiratory insufficiency, causes and treatments. Official coding and sequencing advice is also presented. Coding pitfalls are discussed.
Scribes
In this action plan, the use of scribes is discussed. Requirements needed to meet coding and billing rules are presented.
Secondary Diagnosis Reporting
A basic review of official coding guidelines for secondary diagnosis coding and reporting is presented in this action plan.
Secondary Diagnosis Reporting on Outpatient Encounters
Learn why it is important to code and report secondary diagnosis codes on outpatient encounters such as emergency department, ancillary, clinic and outpatient surgery records.
Sepsis Coding and Sequencing Guidelines
This action plan provides a working knowledge of the pathophysiology, diagnosis and treatment of bacteremia, septicemia, SIRS, sepsis, severe sepsis and septic shock to help the coder understand these conditions and what to look for in the record in order to accurately assign a code.
Shared Visit Services
In this action plan, shared services definitions and the billing requirements are presented. Documentation requirements and coding pitfalls are also reviewed.
Shock Diagnosis Coding in ICD-10-CM
In this action plan, the different types of "shock" diagnoses will be discussed. Detailed clinical information is presented to help the coder clinically validate the specific type of shock. Coding guidelines, references and tips are presented regarding the different types of shock.
Shoulder Procedures Coding in CPT Part 1- Understanding Anatomy and Terminology
This action plan reviews key anatomy of the shoulder joint that is crucial to understand in order to assign shoulder procedure codes in CPT. Common surgical terms are reviewed and descriptions of surgeries provided along with informational photos and videos. This Action Plan is a prerequisite to Shoulder Procedures CPT Coding Part 2 – Understanding Code Reporting and Associated Edits.
Shoulder Procedures Coding in CPT Part 2- Understanding Code Reporting and Associated Edits
This action plan explains the NCCI edits that affect multiple code reporting of shoulder CPT procedures. It is crucial for a coder to understand the NCCI edits and how they affect CPT coding and reporting. Modifiers are also discussed. Key coding challenges along with official coding guidance related to shoulder procedure CPT coding are presented.
Sinus Surgery (Endoscopic) Coding in CPT
This action plan helps the coder to understand endoscopic sinus surgery procedures in CPT. Nasal and sinus anatomy, terminology and videos are presented to assist the coder in understanding the areas involved in the procedures. In addition, common coding pitfalls are described. Official guidance with NCCI guidelines are also presented.
Sinus Surgery (OPEN) Coding in CPT
In this action plan, the coder will learn how to assign CPT codes for OPEN sinus procedures. Although rare in nature, coding of open sinus procedures presents challenges to coders, especially in understanding the anatomy. The action plan discusses the anatomy, open vs FESS approaches and provides photos and examples of different open sinus procedures. A 10-question quiz follows.
Skin and Muscle Graft Coding in CPT Part 1- Understanding Anatomy and Terminology
In this action plan, the anatomy and definitions frequently seen in skin and muscle graft operative reports are presented. It is crucial that the coder have an understanding of the anatomy of the tissues and the types of grafts performed, and their purpose. After completing this Action Plan, the coder can progress to Part 2 which addresses the actual coding.
Skin and Muscle Graft Coding in CPT Part 2- Understanding Code Reporting and Associated Edits
This action plan explains the NCCI edits that affect multiple code reporting of skin and muscle graft CPT procedures. It is crucial for a coder to understand the NCCI edits and how they affect CPT coding and reporting. Key coding challenges along with official coding guidance related to the CPT coding of skin and muscle grafts are presented.
Skin Graft Coding in ICD-10-PCS
This action plan reviews the various types of skin grafts from a clinical and surgical perspective. Proper root operations, body systems, and qualifiers for the various types of grafts will be discussed and presented. Videos are used to enhance the coder’s understanding of these procedures.
Spinal Decompression Coding in ICD-10-PCS
In this action plan, spinal decompression methods and the difference between laminotomy and laminectomy will be discussed.
Spinal Fusion Part 1- Overview of Spinal Fusion
This action plan will look at the spinal fusion procedure, with special attention placed on recognizing the components of approach and instrumentation.
Spinal Fusion Part 2- Dissecting an Operative Report
In this action plan coders will learn to read a spinal fusion operative report and recognize the information needed to obtain accurate codes. ICD-9-CM, CPT and ICD-10-PCS codes are assigned. It is recommended that the coder complete Part 1 of the Spinal Fusion action plan prior to attempting Part 2.
Spinal Fusion Part 3- Coding Clinic Review
In this action plan coders will review relevant Coding Clinics related to spinal fusions. It is recommended that the coder complete Part 1 and 2 of the Spinal Fusion action plan prior to attempting Part 3.
Spinal Fusion Part 4- CPT Assistant Review
In this action plan coders will review relevant CPT Assistant articles related to spinal fusion. It is recommended that the coder complete Part 1 and 2 of the Spinal Fusion action plan prior to attempting Part 4.
Streamline Your Query Process
This action plan will help the coder learn how to more quickly gather clinical indicators and write queries more productively.
Surgical Modifiers
In this action plan, the use of surgical modifiers is presented. Definitions and requirements for use are also discussed.
Swing Bed Coding in ICD-10-CM
In this action plan, the coder will learn how to choose a principal diagnosis on Swing Bed accounts. This can be an area of confusion for coders, depending on the reason for transfer to the Swing Bed. Coding guidelines are presented along with case scenarios. Secondary diagnosis reporting is also discussed.
Teaching Physicians for E&M
In this action plan will learn about the teaching physician guidelines. Definitions and requirements for coding are presented.
Telehealth and Telemedicine
In this action plan, the coder will learn the nuances of telehealth and telemedicine coding and billing. Definitions and documentation requirements are discussed.
Telehealth and Telemedicine for COVID-19
In this action plan, the coder will learn the nuances of telehealth and telemedicine CPT professional fee and ancillary staff coding and billing during the COVID-19 pandemic. Some of the normal requirements have been relaxed for the COVID-19 pandemic period. Definitions and documentation requirements are discussed regarding these.
Time-Based EM
In this action plan, time based evaluation and management coding is presented. Documentation requirements and important caveats are discussed.
Time-Based Evaluation and Management Office and Other Outpatient Services 99202-99215
In this action plan, time based evaluation and management coding is presented as it relates to changes as of CY2022 and codes 99202-99215. Documentation requirements and important caveats are discussed.
Tips to Efficiently Read a Medical Record for Coding
In this action plan, coders can read various tips from their colleagues on what they do to read a medical record and code more efficiently. Tips are divided by area such as what order to review the record, maneuvering in specific E. H. R. areas, query tips, resource tips and encoder tips. A 5 question quiz follows.
Toe Amputation Procedure Coding in ICD-10-PCS
Coders sometimes struggle when coding toe amputations. The root operation, body part value and qualifier selection can be daunting unless the coder knows how and why to select these values. In this session, foot bone and joint anatomy is reviewed along with a description of each type of toe amputation. The difference between a toe body part value vs a foot body part value will be discussed as code assignment will be made depending on what part of the toe or foot the amputation is performed on. Qualifiers are extensively discussed and case examples presented.
Transgender Procedures Coding in ICD-10-PCS
This action plan will discuss transgender surgeries and what root operations are applicable for these various procedures.
Transitional Care Management
In this action plan, transitional care management is defined and documentation requirements presented.
Traumatic Fracture Coding Part 1- Diagnosis Coding
A review of the resources that relate to the diagnosis coding of fractures and bone injuries is presented within this action plan. In Part 2, Traumatic Fracture ICD-10-PCS procedure coding is discussed.
Traumatic Fracture Coding Part 2- Procedure Coding
A review of the resources and procedural information that addresses fracture repair procedures is discussed in this action plan.
Underdosing and Noncompliance of Medication ICD-10-CM Coding
In this action plan, the coder will learn what underdosing is and how to assign the appropriate ICD-10-CM codes. Noncompliance codes are also reviewed. Sequencing of these codes is also presented in case examples.
Urinalysis: Understanding the Test
This action plan is designed to help you increase your coding productivity by enhancing your clinical knowledge about diagnostic testing. Having a working knowledge of what common laboratory findings reveal may eliminate the need to do extensive research during the actual coding process. The coder will be able to make quicker decisions about the choice of principal or secondary diagnoses, or the need for a query just by understanding basic diagnostic tests. This action plan will focus on an overview of urinalysis and what this test may reveal about disease processes.
Vascular Access Device ICD-10-PCS Coding
This action plan will describe the various types of vascular access devices used in medical care. ICD-10-PCS presents challenges in coding these various vascular access devices given the different components and different ways they are inserted. This action plan explains the differences and how to assign codes for each type.
Ventricular Shunt for Hydrocephalus Coding in ICD-10-PCS
In this action plan, the coder will learn what hydrocephalus is and the various shunt procedures performed to correct it. The ventricular shunt will be described along with a video and photos provided. Descriptions of each type of procedure are provided as this can be challenging for the coder. The coder will learn the proper root operations for the differing procedures.
Vitrectomy Coding in CPT
In this Action Plan, the coder will learn what a vitrectomy is, and the difficulties encountered in selecting a correct CPT code. Photos and videos are used to help the coder understand the procedure. A terminology key is also included along with descriptions of the different types of vitrectomies.
White Blood Cell Count: Understanding the test
This action plan is designed to help you increase your coding productivity by enhancing your clinical knowledge about diagnostic testing. Having a working knowledge of what common laboratory findings reveal may eliminate the need to do extensive research during the actual coding process. The coder will be able to make quicker decisions about the choice of principal or secondary diagnoses, or the need for a query just by understanding basic diagnostic tests. This action plan will focus on an overview of white blood cell count and what this test may reveal about disease processes.
Writing Effective Physician Queries
Next to selection of principal diagnosis, writing physician queries could be the hardest part of coding. This Action Plan will give a brief historical background of queries and when they should be written. Coders will learn what constitutes a leading query and how to avoid one by examining examples. Opportunity will be given to practice writing nonleading queries.