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ii ®Official CPC Certification Study Guide Fourth Edition (2014) ... Official CPC® Certification Study Guide Fourth Edition (2014) v Contents Breast, ...
Fourth Edition



Official CPC® Certification Study Guide Contributors: Katherine Abel, CPC, CPB, CPMA, CPC-I Debra A. Apfel, RN, BA, CPC, CPMA Carrie Bosela, CPC, CPC-I Rhonda Buckholtz, CPC, CPC-I, CPMA, CGSC, CPEDC, COBGC, CENTC Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC Shelly Cronin, CPC, CPMA, CPPM, CPC-I, CANPC, CGIC, CGSC Bill Dacey, MBA, MHA, CPC, CPC-I Kelly Dennis, CPC, CPC-I, CANPC Mary Divine, CPC, CPC-H, CPC-I, CUC Brad Ericson, MPC, CPC, COSC Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD Raemarie Jimenez, CPC, CPB, CPMA, CPC-I CANPC, CRHC Dolly Perrine, CPC, CPMA, CPC-I, CUC Jean Pryor, CPC, CPMA, CPC-I, CIMC Dorothy Steed, CPC-H, CPCO, CPMA, CPC-I, CEMC, CFPC Kate Tierney, CPC, CPC-P, CPMA, CEDC, CEMC, CGSC, COBGC G. John Verhovshek, MA, CPC Susan Ward, CPC, CPC-H, CPC-I, CEMC, CPCD, CPRC Reviewers: Lynn Anderanin, CPC, CPC-I, COSC Nicole Benjamin, CPC, CPC-I, CEDC Glade B. Curtis, MD, MPH, FACOG, CPC, CPPM, CPC-I, COBGC Jennifer Hume, CPC, CPCO, CPMA, CEMC Lindsay-Anne McDonald Jenkins, CPC, CPC-H, CPC-I, CPMA, CANPC, CIRCC, RN, CRNA (retired) Vandna Kejariwal, CPC, CPC-H, CPMA, CPC-I, CEDC Barbara Pross, CPC, CPMA, CPC-I, CEDC, CEMC, COBGC Carrie Lynn Rawlings, CPC, CPMA, CPC-I, CCVTC, CEMC Alice Reybitz, RN, BA, CPC, CPC-H, CPC-I Carrie Severson, CPC, CPC-H, CPMA, CPC-I Kathy Skolnick, CPC, CPCO, CPMA, CPC-I Charleen Yamasato, CPC, CPC-I Production: Dianne Allred, Designer, Desktop Publisher Michelle A. Dick, Copy Editor Renee Dustman, Copy Editor Tina M. Smith, Desktop Publisher

ii

Official CPC® Certification Study Guide Fourth Edition (2014)

© 2013, Cengage Learning ALL RIGHTS RESERVED: No part of this work covered by the copyright herein may be reproduced, transmitted, stored, or used in any form or by any means graphic, electronic, or mechanical, including but not limited to photocopying, recording, scanning, digitizing, taping, Web distribution, information networks, or information storage and retrieval systems, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without the prior written permission of the publisher. For product information and technology assistance, contact us at Cengage Learning Customer & Sales Support, 1-800-354-9706. For information about coding, the technical content of the book, and AAPC, contact us at 1-800-626-2633. For permission to use material from this text or product, submit all requests online at www. cengage.com/permissions. Further permissions questions can be emailed to [email protected] ISBN: 9781285451312 Cengage Learning is a leading provider of customized learning solutions with office locations around the globe, including Singapore, the United Kingdom, Australia, Mexico, Brazil and Japan. Locate your local office at: international.cengage.com/region AAPC (www.aapc.com) is the nation’s largest training and credentialing association for the business side of medicine with more than 124,000 members representing physician offices, outpatient facilities, and payer environments. AAPC certifications encompass the entire business side of provider care, with physician coding (CPC®), the hospital outpatient facility (CPC-H ®), payer perspective coding (CPC-P®), interventional radiology cardiovascular coding (CIRCC™), medical auditing (CPMA™), medical compliance (CPCO™), and practice management (CPPM™). All certifications demonstrate a strong hands on, working knowledge to support cleaner claim submission, faster reimbursement, fewer denials, and better run practices. Specialty coding credentials are currently offered in 20 different fields of expertise. AAPC offers continuing education for all our credentials through local chapters, workshops, webinars, a monthly newsmagazine (Cutting Edge), other publications, and conferences

CPT ® copyright 2013 American Medical Association. All rights reserved.



Contents Chapter 1 The Business of Medicine . . . . . . . . . . . . . . . . . . . . . 1 Understanding RBRVS . . . . . . . . . . . . . . . . . . . . Medical Necessity. . . . . . . . . . . . . . . . . . . . . . . . . The Need for Privacy and Security . . . . . . . . . . Fraud and Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . The Need for Compliance Rules and Audits . . The OIG Work Plan. . . . . . . . . . . . . . . . . . . . . . . What AAPC Will Do for You. . . . . . . . . . . . . . .

2 4 5 6 6 7 8

Chapter 2 Medical Terminology and Anatomy Review . . . . 13 Medical Terminology . . . . . . . . . . . . . . . . . . . . Integumentary System. . . . . . . . . . . . . . . . . . . . Musculoskeletal System. . . . . . . . . . . . . . . . . . . Cardiovascular System . . . . . . . . . . . . . . . . . . . Lymphatic System. . . . . . . . . . . . . . . . . . . . . . . . Respiratory System (Pulmonary System). . . . Digestive System. . . . . . . . . . . . . . . . . . . . . . . . . Urinary System. . . . . . . . . . . . . . . . . . . . . . . . . . Reproductive Systems . . . . . . . . . . . . . . . . . . . . Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . Endocrine System. . . . . . . . . . . . . . . . . . . . . . . . Hematologic (Hemic) System. . . . . . . . . . . . . . Immune System . . . . . . . . . . . . . . . . . . . . . . . . .

13 17 18 21 24 26 27 28 28 29 30 31 32

Chapter 3 Introduction to ICD-9-CM. . . . . . . . . . . . . . . . . . . 35 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overview of ICD-9-CM Layout. . . . . . . . . . . . Steps to Look Up a Diagnosis Code. . . . . . . . . ICD-9-CM Official Guidelines for Coding and Reporting. . . . . . . . . . . . . . . . . Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35 35 40 41 58

Chapter 4 Introduction to CPT®, Surgery Guidelines, HCPCS Level II, and Modifiers . . . . 61

Sequencing CPT® Codes . . . . . . . . . . . . . . . . . . CPT® Assistant . . . . . . . . . . . . . . . . . . . . . . . . . . CPT® Category II Codes and a Brief Overview of the Physician Quality Reporting System (PQRS) . . . . . . . . . . . . . . . . CPT® Category III Codes. . . . . . . . . . . . . . . . . . CPT® Appendices. . . . . . . . . . . . . . . . . . . . . . . . Surgery Guidelines. . . . . . . . . . . . . . . . . . . . . . . HCPCS Level II. . . . . . . . . . . . . . . . . . . . . . . . . . Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

66 67 67 67 68 69 71 73 79

Chapter 5 Integumentary System. . . . . . . . . . . . . . . . . . . . . . . 83 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy and Medical Terminology. . . . . . . . ICD-9-CM Coding . . . . . . . . . . . . . . . . . . . . . . CPT® Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . . Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

83 84 84 88 95

Chapter 6 Musculoskeletal System. . . . . . . . . . . . . . . . . . . . . 101 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy and Medical Terminology. . . . . . . ICD-9-CM Coding. . . . . . . . . . . . . . . . . . . . . . CPT® Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . HCPCS Level II. . . . . . . . . . . . . . . . . . . . . . . . . Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

101 101 106 109 112 112

Chapter 7 Respiratory, Hemic, & Lymphatic Systems; Mediastinum, and Diaphragm. . . . . . . . . . . . . . . . 117 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy and Medical Terminology. . . . . . . ICD-9-CM Coding. . . . . . . . . . . . . . . . . . . . . . CPT® Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . HCPCS Level II. . . . . . . . . . . . . . . . . . . . . . . . . Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

117 117 119 122 127 128 128

Introduction to CPT® . . . . . . . . . . . . . . . . . . . . 61 National Correct Coding Initiative (NCCI). . 65

CPT ® copyright 2013 American Medical Association. All rights reserved.

Official CPC® Certification Study Guide Fourth Edition (2014)

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Chapter 8 Cardiovascular System . . . . . . . . . . . . . . . . . . . . . 133 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy and Medical Terminology. . . . . . . ICD-9-CM Coding. . . . . . . . . . . . . . . . . . . . . . CPT® Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . Modifiers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HCPCS Level II. . . . . . . . . . . . . . . . . . . . . . . . . Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

133 133 136 139 147 148 149

Chapter 9 Digestive System. . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy and Medical Terminology. . . . . . . ICD-9-CM Coding. . . . . . . . . . . . . . . . . . . . . . CPT® Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . HCPCS Level II Coding. . . . . . . . . . . . . . . . . . Modifiers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

155 155 156 158 162 162 163

Chapter 10 Urinary System and Male Genital System . . . . . 169 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy and Medical Terminology. . . . . . . ICD-9-CM Coding. . . . . . . . . . . . . . . . . . . . . . CPT® Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . HCPCS Level II. . . . . . . . . . . . . . . . . . . . . . . . . Modifiers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

169 169 171 175 180 180 181

Chapter 11 Female Reproductive System . . . . . . . . . . . . . . . . 189 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy and Medical Terminology. . . . . . . ICD-9-CM Coding. . . . . . . . . . . . . . . . . . . . . . CPT® Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . HCPCS Level II Coding. . . . . . . . . . . . . . . . . . Modifiers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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189 189 190 192 195 195 195

Chapter 12 Endocrine and Nervous System . . . . . . . . . . . . . 203 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy and Medical Terminology. . . . . . . ICD-9-CM Coding. . . . . . . . . . . . . . . . . . . . . . CPT® Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . HCPCS Level II. . . . . . . . . . . . . . . . . . . . . . . . . Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

203 203 207 209 217 217 219

Chapter 13 Eye and Ocular Adnexa, Auditory Systems. . . . 225 Eye: Introduction and Anatomy. . . . . . . . . . . Ear: Introduction and Anatomy. . . . . . . . . . . ICD-9-CM Coding. . . . . . . . . . . . . . . . . . . . . . CPT® Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . Medicine Codes . . . . . . . . . . . . . . . . . . . . . . . . HCPCS Level II. . . . . . . . . . . . . . . . . . . . . . . . . Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

225 226 227 230 230 231 231 232

Chapter 14 Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . Types of Anesthesia . . . . . . . . . . . . . . . . . . . . . Anesthesia Coding Terminology. . . . . . . . . . Postoperative Pain Management . . . . . . . . . . ICD-9-CM Coding. . . . . . . . . . . . . . . . . . . . . . CPT® Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . Anesthesia-Related Teaching Rules. . . . . . . . Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

237 237 238 238 239 239 245 246

Chapter 15 Radiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy and Medical Terminology. . . . . . . ICD-9-CM Coding. . . . . . . . . . . . . . . . . . . . . . CPT® Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . Types of Radiological Services. . . . . . . . . . . . The Components of a Radiology Service . . . Diagnostic Ultrasound . . . . . . . . . . . . . . . . . . Radiologic Guidance . . . . . . . . . . . . . . . . . . . .

251 251 252 253 254 255 255 256

CPT ® copyright 2013 American Medical Association. All rights reserved.

Contents

Breast, Mammography . . . . . . . . . . . . . . . . . . Bone/Joint Studies . . . . . . . . . . . . . . . . . . . . . . Radiation Oncology. . . . . . . . . . . . . . . . . . . . . Nuclear Medicine. . . . . . . . . . . . . . . . . . . . . . . HCPCS Level II Coding. . . . . . . . . . . . . . . . . . Modifiers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

257 257 257 258 259 259 259

Chapter 16 Pathology and Laboratory. . . . . . . . . . . . . . . . . . . 265 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy and Medical Terminology. . . . . . . ICD-9-CM Coding. . . . . . . . . . . . . . . . . . . . . . CPT® Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . HCPCS Level II Coding. . . . . . . . . . . . . . . . . . Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

265 265 266 267 272 272 272

Chapter 17 Evaluation and Management . . . . . . . . . . . . . . . . 277 Introduction and Objectives. . . . . . . . . . . . . . 277 E/M Services Defined. . . . . . . . . . . . . . . . . . . .277 CPT® E/M Services Guidelines. . . . . . . . . . . . 278 Key Components of an E/M Service. . . . . . . 278 E/M Service Categories. . . . . . . . . . . . . . . . . . 279 Choosing the E/M Service Level . . . . . . . . . . 287 Diagnosis Coding for E/M Services. . . . . . . . 300 Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

Chapter 18 Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 Anti-infective Immunizations. . . . . . . . . . . . Vaccines and Toxoids. . . . . . . . . . . . . . . . . . . . Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Biofeedback. . . . . . . . . . . . . . . . . . . . . . . . . . . . Dialysis and End Stage Renal Disease Services. . . . . . . . . . . . . . . . . . . Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . Ophthalmological Services & Special Otorhinolaryngologic Services. . . . . Cardiovascular Services . . . . . . . . . . . . . . . . . Noninvasive Vascular Diagnostic Studies . . Pulmonary Studies. . . . . . . . . . . . . . . . . . . . . .

307 308 308 309

Allergy and Immunology . . . . . . . . . . . . . . . . 310 Endocrinology & Neurology and Neuromuscular Procedures . . . . . . . . . . 310 Medical Genetics and Genetic Counseling Services . . . . . . . . . . . . . 310 Central Nervous System Assessments/Tests.311 Hydration, Therapeutic, Prophylactic, Diagnostic Injections/Infusions and Chemotherapy, Highly Complex Drugs or Highly Complex Biologic Agent Administration . . . . . . . . . . . 311 Photodynamic Therapy & Special Dermatological Procedures. . . . . . . . 312 Physical Medicine and Rehabilitation. . . . . . 312 Education and Training for Patient Self-Management . . . . . . . . . . . . . 314 Non-Face-to-Face Nonphysician Services . . 314 Special Services, Procedures, and Reports. . 315 Qualifying Circumstances for Anesthesia & Moderate (Conscious) Sedation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 Other Services and Procedures . . . . . . . . . . . 316 Home Health Procedures and Services. . . . . 316 Home Infusion Procedures. . . . . . . . . . . . . . . 317 Medication Therapy Management Services. 318 Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318

Chapter 19 Tips for Taking an AAPC Certification Exam. . 325 CPC® Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preparing for Your Exam . . . . . . . . . . . . . . . . Exam Registration . . . . . . . . . . . . . . . . . . . . . . Day of the Exam. . . . . . . . . . . . . . . . . . . . . . . . During the Test. . . . . . . . . . . . . . . . . . . . . . . . . Exam Completion. . . . . . . . . . . . . . . . . . . . . . .

325 325 326 326 326 327

Chapter 20 Test Your Knowledge. . . . . . . . . . . . . . . . . . . . . . . 329

309 309 310 310 310 310

CPT ® copyright 2013 American Medical Association. All rights reserved.

Official CPC® Certification Study Guide Fourth Edition (2014)

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Appendix A Answers and Rationales for Chapter Review Questions . . . . . . . . . . . . . . . 353 Chapter 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 11. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 12. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 14. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 16. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 17. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

353 354 356 358 359 362 364 367 369 371 373 375 377 379 382 384 386 388

Appendix B Answers and Rationales for Test Your Knowledge. . . . . . . . . . . . . . . . . . . . 391 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401

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CPT ® copyright 2013 American Medical Association. All rights reserved.

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