Assigning medical codes, module 1

COMPETENCY-BASED
LEARNING MATERIAL

Sector:

INFORMATION AND COMMUNICATION TECHNOLOGY

Qualification:

MEDICAL CODING AND BILLING NC II

Unit of Competency:

ASSIGN MEDICAL CODES

Module Title:

ASSIGNING MEDICAL CODES

Developed by:

TECHNICAL EDUCATION AND SKILLS DEVELOPMENT AUTHORITY

East Service Road, South Superhighway, Taguig City, Metro Manila

Glossary of Terms:

AMA American Medical Association
Conventions
CPT A rule, method, or practice established by usage.
Disease
Current procedural terminology
Efficacy
An interruption, cessation, or disorder of body function, system, or
Eponym organ.
The extent to which a specific intervention, procedure, regimen, or
GPCI service produces a beneficial result under ideal conditions.
HCPCS The name of a disease, structure, operation, or procedure, usually
HIPAA derived from the name of the person who discovered or described it
HPI first.
ICD Geographic Practice Cost Indices
ICD-9-CM
Morbidity Healthcare Common Procedure Coding System
Mortality
PFSH Health Insurance Portability and Accountability Act
ROS
RVU History of Present Illness

International Classification of Diseases

International Classification of Diseases Clinical Modification

The ratio of sick to well in a community.

Death rate.
Patient’s family and social history

Review of Systems

Relative Value Amount

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Program/Course : Medical Coding and Billing NC II
Unit of Competency : Assign Medical Codes
Module Title : Assigning Medical Codes

INTRODUCTION:

This module covers the skills, knowledge and attitude necessary to assign codes for
medical diagnoses, procedures, services, supplies, equipment, and other services.

LEARNING OUTCOMES
Upon completion of this module you should be able to:
1. Assign diagnoses codes
2. Assign codes for procedures and services
3. Assign codes for supplies, equipment and other services

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LO1. Assign Diagnoses Codes

Objective:

Upon completion of this topic participants should be able to analyze medical
documents and accurately code using the ICD-9-CM.

Part 1: INTRODUCTION TO MEDICAL TERMINOLOGY

Medical terminology is a language that defines the human body, disease process or
condition.

WORD PARTS

Word parts are called the building blocks of medical terms. There are four types of word
parts:

1. Root words
2. Combining forms
3. Prefixes
4. Suffixes

Root Words
Root words are called base words.

EXAMPLE: Meaning
Root word artery
arteri nose
rhin skin
dermat vein
phleb heart
cardi

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A root word usually indicates the involved body parts.

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Combining Forms
These are root words with a vowel at the end so that a suffix beginning with a consonant
can be added. The letter O is the most commonly used combining vowel.

EXAMPLE:
angiogram
gastroscope
hepatocele
leukocyte

Root Words/Combining Forms Indicating Color

cyan/o means blue Cyanosis (sigh-ah-NOH-sis) is a blue discoloration of the skin

caused by a lack of adequate oxygen (cyan means blue and -

osis means condition).

erythr/o means red Erythrocytes (eh-RITH-roh-sights) are mature red blood cells

(erythr/o means red and cytes means cells).

leuk/o means white Leukocytes (LOO-koh-sights) are white blood cells (leuk/o
means white and –cytes means cells).

melan/o means black Melanosis (mel-ah-NOH-sis) is any condition of unusual

deposits of black pigment in different parts of the body (melan

means black and -osis means condition).

poli/o means gray Poliomyelitis (poh-lee-oh-my-eh-LYE-tis) is a viral infection of

the gray matter of the spinal cord that may result in paralysis

(poli/o means gray, myel means spinal cord, and -itis means

inflammation).

Prefixes

Prefixes are words that are placed at the beginning of another word. They usually, but not
always, indicate location, time or number.

EXAMPLE: Meaning
Prefix time and events before birth
Prenatal time and events surrounding birth
Perinatal time and events after birth
Postnatal

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Contrasting and Confusing Prefixes

ab- means away from
Abduction - movement of the body away from the median plane

ad- means toward or in the direction of
Adduction - movement of the body toward the median plane

dys- means bad or difficult
Dysuria - difficulty or pain in urination

eu- means good or well
Euthymic - a normally functioning thyroid

hyper- means excessive or above normal
Hyperglycemia - high concentration of glucose in the blood

hypo- means deficient or below normal
Hypoglycemia - low concentration of glucose in the blood

inter- means among or between
Intercapillary - between or among capillary vessels

intra- means inside or within
Intracellular within a cell or cells

sub- means beneath
Subabdominal - below the abdomen

super-/supra- - means above or excessive
Supraclavicular above the clavicle

Suffixes
Suffixes are words that are placed at the end of a root word. They usually, but not always,
indicate procedure, disorder, or disease.

EXAMPLE:

Suffix Meaning

neuroplasty surgical repair of the a nerve

(neur/o means nerve and –plasty means surgical repair)

neuritis inflammation of a nerve

(neur/o means nerve and –itis means inflammation)

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Suffixes related to pathology

-algia means pain or painful condition

Arthralgia - pain in the joint

-dynia means pain

Gastrodynia - pain in the stomach

-itis means inflammation

Arthritis - inflammation of a joint

-malacia means abnormal softening

Chondromalacia - softening of any cartilage

-megaly means large

Cardiomegaly - enlargement of the heart

-necrosis means tissue death

Arterionecrosis - tissue death of an artery or arteries

-sclerosis means abnormal hardening

Arteriosclerosis - hardening of the arteries

-stenosis means abnormal narrowing

Arteriostenosis - abnormal narrowing of the arteries

DIVIDING MEDICAL TERMS

Dividing a medical term into word parts will help in figuring out a meaning of an unfamiliar
medical word. Here are some important points to remember when dividing medical terms:

1. Always start at the end of the word, with the suffix, and work toward the beginning.
2. After separating the word parts, identify the meaning of each word. This should give

you a definition of the term.
3. Some word parts have one meaning. It is necessary to determine the context in

which the term is being used or which body system it is being referred to.

EXAMPLE:
The word otorhinolaryngology is made up of three combining forms and a suffix
word.

 The suffix –ology means study of.
 The root word laryng means larynx and throat.
 The combining form rhin/o means the nose.
 The combining form ot/o means ear.
 Together they form the word otorhinolaryngology which means the study

of ears, nose and throat.

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SINGULAR AND PLURAL FORMS

Many medical terms came from Latin or Greek words. As a result of this, there are unusual
rules for changing a singular word into its plural form. English rules have also been
adopted for some commonly used terms. Table 1.1 provides some guidelines to help you
better understand how unusual medical terms are given its plural forms.

Table 1.1

GUIDELINES TO UNUSUAL PLURAL FORMS

Guidelines Singular Plural
bursae
1. If the term ends in a, the plural is usually formed by adding an e. bursa vertebrae
appendices
vertebra
indices
2. If the term ends in ex or ix, the plural is usually formed by appendix diagnoses
changing the ex or ix to ices.
metastases
index arthritides

3. If the term ends in is, the plural is usually formed by changing diagnosis meningitides
the is to es. phalanges
meninges
metastasis criteria
ganglia
4. If the term ends in itis, the plural is usually formed by changing arthritis diverticula
the is to ides. ova
alveoli
meningitis malleoli

5. If the term ends in nx, the plural is usually formed by changing phalanx
the x to ges. meninx

6. If the term ends in on, the plural is usually formed by changing criterion
the on to a. ganglion
diverticulum
7. If the term ends in um, the plural usually is formed by changing ovum
the um to a.

8. If the term ends in us, the plural is usually formed by changing alveolus
the us to i. malleolus

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BASIC MEDICAL TERMS

Sign, Symptom, Syndrome

Sign: It is an objective evidence of a disease. Objective means the sign can be
evaluated by the patient or others.
EXAMPLE: Fever

Symptom: It is a subjective evidence of a disease. Subjective means the sign can be
evaluated only by the patient.
EXAMPLE: Feverish

Syndrome: It is a set of signs and symptoms that occur together as part of a disease
process.
EXAMPLE: Dengue shock syndrome

Acute, Chronic, Remission

Acute It is a condition that is rapid in onset, not prolonged and sometimes used to
mean severe.
Chronic It is a condition that is of long duration.
Remission It is the disappearance in the severity of the symptoms of a disease.

Laceration, Lesion

Laceration A torn or jagged wound.

Lesion A pathologic change of the tissues due to a disease or an injury.

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Infection, Inflammation

Infection Invasion of the body with organisms that have the potential to cause disease.
Inflammation: Localized response to an injury or destruction of tissue.

Eponym

Eponym is the name of a disease, structure, operation, or procedure, usually derived from
the name of the person who discovered or described it first.

EXAMPLE:
Alzheimer’s disease
Adson clamp
McBurney’s incision

Acronym

Acronym is a word formed from the initial letters or groups of letters of words in a set
phrase or series of words.

EXAMPLE: Stands For
Acronym Chronic obstructive pulmonary disease
COPD Coronary artery bypass graft
CABG

Abbreviation

Abbreviation is a shortened or contracted form of a word or phrase used to represent the
whole.

EXAMPLE: Stands for
Abbreviation Doctor
Dr. pounds
lb. kilo or kilogram
kg

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LEARNING EXERCISES 1.1

1. The prefix meaning surrounding is _______.
inter intra peri

2. Pain which can only be observed by the patient is _______.
sign symptom prognosis

3. It is a word that is placed at the end of the root word. _______

combining form suffix prefix

4. A disease named after the person who discovered it. _______

eponym abbreviation acronym

5. A localized response to injury. _______

Inflammation infection disease

6. These are called the base words. _______

combining form root words suffix

7. Divide the medical term gastroduodenoscopy into the combining form, root word and
suffix.

References:
Stedman’s Electronic Medical Dictionary
http://webtools.delmarlearning.com/sample_chapters/1401860265_Chapter1.pdf

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Medical Documentation

Medical documentation is a system of recording the care, clinical assessment, professional
judgment and critical thinking by healthcare professionals like doctors, nurses, or other
allied health professionals (therapist and dietitians).

Guidelines for Medical Record and Clinical Documentation

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CLINICAL COMPETENCE IN RELATION TO DOCUMENTATION

1. Medical documentation promotes high standard of clinical care.
2. It improves communication and dissemination of information between and across

service providers.
3. It provides an accurate account of treatment, intervention and care planning.
4. It improves goal setting and evaluation of care outcomes.
5. It improves early detection of problems and changes in health status.

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PART 2: THE MEDICAL REPORT

Medical report is a documentation of the patient’s medical history and care provided by
healthcare professionals.

Types of Medical Reports

Basically, there are four basic types of a medical report:

1. History and Physical Examination
2. Consultation
3. Operative Report
4. Discharge Summary

Other types of medical reports are:

1. Progress notes or SOAP (Subjective, Objective, Assessment and Plan)
2. Radiology Report
3. Pathology Report
4. Autopsy Report
5. Emergency Department Report

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History and Physical Examination (H&P)

History and Physical Examination or H&P report is the most common medical report. It
gives emphasis on the history of the patient’s disease and physical examination.

Sample History and Physical Examination (H&P) Report

DATE OF ADMISSION: MM/DD/YYYY

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old white male who went to the
emergency room with sudden onset of severe left flank and left lower quadrant abdominal
pain associated with gross hematuria. The patient had a CT stone profile which showed no
evidence of renal calculi. He was referred for urologic evaluation. When seen in our office,
the patient continued to have mild left flank pain and no difficultly voiding. Urinalysis
showed 1+ occult blood. Intravenous pyelogram was done which demonstrated a low-lying
malrotated right kidney. There was no evidence of renal or ureteral calculi
or hydronephrosis. Urine cytology was negative for malignant cells. The patient
subsequently had a CT renal scan with contrast. This showed what appeared to be an
infarction of an area of the lower pole of the left kidney. It was suggested that a renal MRI
be done for further delineation of this problem. He had a right kidney which was malrotated
but was otherwise normal. The patient is admitted at this time for complete urologic
evaluation.

PAST MEDICAL HISTORY: He had surgery on his right knee two years ago.

MEDICATIONS: He takes Diovan 80 mg with hydrochlorothiazide 12.5 mg daily and
hydrocodone as needed for pain.

ALLERGIES: There are no known drug allergies.

SOCIAL HISTORY: He is single. Denies use of alcohol. Smokes one pack of cigarettes
per day over the last 10 years.

FAMILY HISTORY: Father died of cancer, type unknown. Mother is living and well.

REVIEW OF SYSTEMS: Neurologic: Denies vertigo, syncope, convulsions or headaches.
Musculoskeletal: No muscle or joint pain. Cardiorespiratory: Denies shortness of breath,
dyspnea on exertion, chest pain, cough or hemoptysis. Gastrointestinal: He has occasional
indigestion. Denies emesis, melena, constipation, diarrhea or rectal
bleeding. Genitourinary: As noted in HPI.

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PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse is 72 and regular, respirations 18 and regular, blood pressure 122/78.
GENERAL: Well-developed, well-nourished white male in no acute distress. Alert and
cooperative.
HEENT: Pupils are equal, round and reactive to light and accommodation. Extraocular
movements are intact. Pharynx is clear. Tympanic membranes are normal.
NECK: Supple. No thyromegaly. No cervical adenopathy.
CHEST: Symmetrical with equal expansion.
LUNGS: Clear to percussion and auscultation.
HEART: No cardiomegaly. No thrills or murmurs. Normal sinus rate and rhythm.
ABDOMEN: There is slight left flank tenderness to deep palpation. There is no guarding or
rebound tenderness. Bowel sounds are normal.
EXTREMITIES: No peripheral edema or varicosities.
GENITALIA: Normal external male genitalia. No penile lesions. Testes are descended
bilaterally and are normal to palpation.
RECTAL: The prostate is small, benign and nontender.

IMPRESSION: Hematuria associated with left flank pain and left renal infarction.

PLAN: Admitted at the present time for further evaluation.

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Consultation

Consultation report is used when one physician asks another to consult on a patient’s
specific medical problem. For instance, an internist may consult a cardiologist if his patient
complains of having chest pain.

Sample Consultation Report

DATE OF CONSULTATION: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

CONSULTING PHYSICIAN: Jane Doe, MD

REASON FOR CONSULTATION: Surgical evaluation for coronary artery disease.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who has a
known history of coronary artery disease. She underwent previous PTCA and stenting
procedures in December and most recently in August. Since that time, she has been
relatively stable with medical management. However, in the past several weeks, she
started to notice some exertional dyspnea with chest pain. For the most part, the pain
subsides with rest. For this reason, she was re-evaluated with a cardiac catheterization.
This demonstrated 3-vessel coronary artery disease with a 70% lesion to the right coronary
artery; this was a proximal lesion. The left main had a 70% stenosis. The circumflex also
had a 99% stenosis. Overall left ventricular function was mildly reduced with an ejection
fraction of about 45%. The left ventriculogram did note some apical hypokinesis. In view of
these findings, surgical consultation was requested and the patient was seen and evaluated
by Dr. Doe.

PAST MEDICAL HISTORY:
1. Coronary artery disease as described above with previous PTCA and stenting

procedures.
2. Dyslipidemia.
3. Hypertension.
4. Status post breast lumpectomy for cancer with followup radiation therapy to the chest.

ALLERGIES: None.

MEDICATIONS: Aspirin 81 mg daily, Plavix 75 mg daily, Altace 2.5 mg daily, metoprolol 50
mg b.i.d. and Lipitor 10 mg q.h.s.

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SOCIAL HISTORY: She quit smoking approximately 8 months ago. Prior to that time, she
had about a 35- to 40-pack-year history. She does not abuse alcohol.

FAMILY MEDICAL HISTORY: Mother died prematurely of breast cancer. Her father died
prematurely of gastric carcinoma.

REVIEW OF SYSTEMS: There is no history of any CVAs, TIAs or seizures. No chronic
headaches. No asthma, TB, hemoptysis or productive cough. There is no congenital heart
abnormality or rheumatic fever history. She has no palpitations. She notes no nausea,
vomiting, constipation, diarrhea, but immediately prior to admission, she did develop some
diffuse abdominal discomfort. She says that since then, this has resolved. No diabetes or
thyroid problem. There is no depression or psychiatric problems. There are no
musculoskeletal disorders or history of gout. There are no hematologic problems or blood
dyscrasias. No bleeding tendencies. Again, she had a history of breast cancer and
underwent lumpectomy procedures for this with followup radiation therapy. She has been
followed in the past 10 years and mammography shows no evidence of any recurrent
problems. There are no recent fevers, malaise, changes in appetite or changes in weight.

PHYSICAL EXAMINATION: Her blood pressure is 120/70, pulse is 80. She is in a sinus
rhythm on the EKG monitor. Respirations are 18 and unlabored. Temperature is 98.2
degrees Fahrenheit. She weighs 160 pounds. She is 5 feet 4 inches. In general, this was
an elderly-appearing, pleasant female who currently is not in acute distress. Skin color and
turgor are good. Pupils were equal and reactive to light. Conjunctivae clear. Throat is
benign. Mucosa was moist and noncyanotic. Neck veins not distended at 90 degrees.
Carotids had 2+ upstrokes bilaterally without bruits. No lymphadenopathy was
appreciated. Chest had a normal AP diameter. The lungs were clear in the apices and
bases, no wheezing or egophony appreciated. The heart had a normal S1, S2. No
murmurs, clicks or gallops. The abdomen was soft, nontender, nondistended. Good bowel
sounds present. No hepatosplenomegaly was appreciated. No pulsatile masses were felt.
No abdominal bruits were heard. Her pulses are 2+ and equal bilaterally in the upper and
lower extremities. No clubbing is appreciated. She is oriented x3. Demonstrated a good
amount of strength in the upper and lower extremities. Face was symmetrical. She had a
normal gait.

IMPRESSION: This is a (XX)-year-old female with significant multivessel coronary artery
disease. The patient also has a left main lesion. She has undergone several PTCA and
stenting procedures within the last year to year and a half. At this point, in order to reduce
the risk of any possible ischemia in the future, surgical myocardial revascularization is
recommended.

PLAN: We will plan to proceed with surgical myocardial revascularization. The risks and
benefits of this procedure were explained to the patient. All questions pertaining to this
procedure were answered.

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Operative

Operative report is a document produced by a surgeon or other physicians who have
participated in a surgical intervention. It contains the diagnoses, the procedure done on the
patient, instruments used during the procedure, and how the operation was done.

Sample Operative Report

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Sick sinus syndrome, status post pacemaker insertion.
2. Infected pacemaker with exposed wires.
3. Coronary artery disease with history of coronary artery bypass graft.
4. Essential hypertension.

POSTOPERATIVE DIAGNOSES:
1. Sick sinus syndrome, status post pacemaker insertion.
2. Infected pacemaker with exposed wires.
3. Coronary artery disease with history of coronary artery bypass graft.
4. Essential hypertension.

OPERATIONS PERFORMED:
1. Explant of pacemaker generator and two wires under fluoroscopic guidance and xenon

laser.
2. Pocket revision.
3. Intraoperative transesophageal echocardiography with interpretation.

SURGEON: John Doe, MD

ASSISTANT: None.

ANESTHESIA: General.

ANESTHESIOLOGIST: Jane Doe, MD

COMPLICATIONS: None.

DRAINS: One #7 Jackson-Pratt in the subcutaneous space.

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DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and
anesthetized without difficulty and prepped and draped in a sterile fashion. Previous
incision that had been used to insert the pacemaker was excised and the pacemaker was
dissected out from the subcutaneous pocket. Cultures were obtained from the pocket. I
had initially planned on making my incision so as to include the area of skin that had been
worn through by the pacemaker leads, but this was impracticable because the lead had
worn out quite a way below the clavicle and I was concerned about accessing the
subclavicular region through this approach. The leads that had eroded through the skin
inferiorly was excised separately in an elliptical fashion.

The pacemaker was dissected out. The infected tissue in the subcutaneous space was
removed via electrocautery. I disconnected the atrial lead and placed a stylette into it. The
screw was withdrawn under direct vision and the lead was removed without difficulty. The
ventricular lead was then subsequently removed. Again, I placed a stylette and placed
tractional lead. I was not able to remove it. It was transected and sized to a #2 locking
device. The locking device was inserted and secured with heavy silk. A 14-French laser
and laser sheath were obtained and placed over the locking device. The laser was
activated under fluoroscopic guidance. The lead was removed in its entirety without
difficulty. Tips of both leads were sent down for culture as well.

At this point, reassessed the transesophageal echocardiography. No pericardial effusion
was noted. The patient was well preserved with left ventricular function. The wound was
irrigated with saline antibiotic solution. I was somewhat concerned about the thinness of
the tissue between the area where the skin eroded through where the lead had been
exposed in my primary incision. The skin was somewhat thin here, but it appeared to be
viable. I went ahead and placed my drain through the elliptical incision that was used to
excise the erosion. Around the drain, I closed the skin with interrupted nylon. The
subcutaneous tissues of the primary incision were closed with 2-0 Vicryl and the skin with
surgical clips. A sterile pressure dressing was applied.

Needle, sponge and instrument counts were correct at the end of the case. Once again, we
rechecked the transesophageal echocardiography and felt no evidence of effusion. The
patient was extubated and transferred to the recovery room in satisfactory condition.

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Discharge Summary

Discharge summary is a clinical report prepared by a physician at the conclusion of a
hospital stay or series of treatments. It contains the chief complaint, diagnostic findings, the
therapy given to the patient, and instructions or recommendations upon discharge.

Sample Discharge Summary Report

DATE OF ADMISSION: MM/DD/YYYY

DATE OF DISCHARGE: MM/DD/YYYY

DISCHARGE DIAGNOSES:
1. Vasovagal syncope, status post fall.
2. Traumatic arthritis, right knee.
3. Hypertension.
4. History of recurrent urinary tract infection.
5. History of renal carcinoma, stable.
6. History of chronic obstructive pulmonary disease.

CONSULTANTS: None.

PROCEDURES: None.

BRIEF HISTORY: The patient is an (XX)-year-old female with history of previous stroke;
hypertension; COPD, stable; renal carcinoma; presenting after a fall and possible syncope.
While walking, she accidentally fell to her knees and did hit her head on the ground, near
her left eye. Her fall was not observed, but the patient does not profess any loss of
consciousness, recalling the entire event. The patient does have a history of previous falls,
one of which resulted in a hip fracture. She has had physical therapy and recovered
completely from that. Initial examination showed bruising around the left eye, normal lung
examination, normal heart examination, normal neurologic function with a baseline
decreased mobility of her left arm. The patient was admitted for evaluation of her fall and to
rule out syncope and possible stroke with her positive histories.

DIAGNOSTIC STUDIES: All x-rays including left foot, right knee, left shoulder and cervical
spine showed no acute fractures. The left shoulder did show old healed left humeral head
and neck fracture with baseline anterior dislocation. CT of the brain showed no acute
changes, left periorbital soft tissue swelling. CT of the maxillofacial area showed no facial
bone fracture. Echocardiogram showed normal left ventricular function, ejection fraction
estimated greater than 65%.

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HOSPITAL COURSE:

1. Fall: The patient was admitted and ruled out for syncopal episode. Echocardiogram
was normal, and when the patient was able, her orthostatic blood pressures were within
normal limits. Any serious conditions were quickly ruled out.

2. Status post fall with trauma: The patient was unable to walk normally secondary to
traumatic injury of her knee, causing significant pain and swelling. Although a scan
showed no acute fractures, the patient's frail status and previous use of cane prevented
her regular abilities. She was set up with a skilled nursing facility, which took several
days to arrange, where she was to be given daily physical therapy and rehabilitation
until appropriate for her previous residence.

DISCHARGE DISPOSITION: Discharged to skilled nursing facility.

ACTIVITY: Per physical therapy and rehabilitation.

DIET: General cardiac.

MEDICATIONS: Darvocet-N 100 one tablet p.o. q.4-6 h. p.r.n. and Colace 100 mg p.o.
b.i.d. Medications at Home: Zestril 40 mg p.o. daily, Plavix 75 mg p.o. daily, Norvasc 5 mg
p.o. daily, hydrochlorothiazide 50 mg p.o. daily, potassium chloride 40 mEq p.o. daily,
Atrovent inhaler 2 puffs q.i.d., albuterol inhaler 2 puffs q.4-6 h. p.r.n., clonidine 0.1 mg p.o.
b.i.d., Cardura 2 mg p.o. daily, and Macrobid for prophylaxis, 100 mg p.o. daily.

FOLLOWUP:
1. Follow up per skilled nursing facility until discharged to regular residence.
2. Follow up with primary provider within 2-3 weeks on arriving to home.

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Part 3: MEDICAL CODING SYSTEMS

Medical coding system is a system of transforming narrative description of diseases,
injuries, and healthcare procedures into numeric or alphanumeric designations. This is
done in order to help medical professionals communicate information about the patients’
conditions, treatment and medical history.

The three major coding systems are the following:
1. International Classification of Diseases (ICD).
2. Current Procedural Terminology (CPT).
3. Healthcare Common Procedural Coding System (HCPCS).

INTERNATIONAL CLASSIFICATION OF DISEASES (ICD)

The International Classification of Diseases or ICD is the official list of categories of
diseases. ICD was first used in England in the 1600s. By the late 1800s, it was used in the
United States for reporting statistics on morbidity and mortality. Several revisions have
been made in the ICD and to date ICD-9-CM is the classification being used in the United
States.

The International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM)

The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-
CM), is the medical classification for the collection of information regarding disease and
injury. The ICD-9-CM is organized in three volumes. Volume 1 and Volume 2 are used to
classify diagnoses and Volume 3 is used to classify inpatient procedures that are billed by
the hospitals.

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INFORMATION SHEET # 1

Purposes of ICD-9-CM

ICD-9-CM converts medical diagnoses and inpatient hospital procedures into numbers and
this is done primarily because of five reasons and these are the following:

1. Reporting and Research
a. Reporting: This is to provide standard and defined way of reporting. For
example, the disease back pain is coded the same way. Without ICD coding,
back pain can be coded as “pain in the back” or “pain: back.”
b. Research: ICD is also used in the study of effects of medication on patients
with certain diseases. For example, a drug company wants to know the
efficacy of their new drug on patients with brain cancer, ICD-9-CM can be
used to identify a population with this disease and to include this population in
their study.

2. Monitoring the quality of patient care: This is used to improve services being
rendered to patients by healthcare providers.

3. Communications and transactions: Providers like physicians communicate with
payers or insurance companies about the diagnosis and the services provided to
patients using the ICD-9-CM.

4. Reimbursement: ICD-9-CM is used for reimbursement purposes so that services
given to patients can be coded correctly in order to give the proper reimbursements
to hospital and/or physicians.

5. Administrative uses: Administrative budgeting, staffing, and marketing tasks that
require the evaluation of patient types and services can be supported by the review
of the ICD-9-CM codes reported for each patient.

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LEARNING EXERCISES 1.2

Identify the following purpose of ICD-9-CM coding in the following cases as Research (R),
Quality (Q), Communication (C), Reimbursement (RM), or Administrative (A)

1. A pharmaceutical company wants to know if their new drug is effective. _______

2. A hospital board would like a vaccination campaign because of a reduction in services
to patients over the last year. _______

3. A wrong set of codes was sent to an insurance company resulting in incorrect billing
and reimbursement and a new set of codes had to be resubmitted. _______

4. A hospital asked the patients who underwent knee surgery to complete a survey to
determine if their services were satisfactory. _______

5. A patient wanted to know the coverage policy of his insurance. _______

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INFORMATION SHEET # 1

Understanding the ICD-9-CM

Coding requires familiarity on the format of ICD-9-CM, its rules and its conventions in order
to help the coder locate the necessary code for a disease or procedure. ICD-9-CM uses a
codebook and it has three volumes:

Volume 1: Tabular List of Diseases and Injuries
Volume 2: Alphabetic Index of Diseases and Injuries
Volume 3: Tabular List and Alphabetic Index to Procedures

Volume 1: Tabular List of Diseases and Injuries

The Tabular List of Diseases and Injuries (Volume 1) has three subdivisions:
1. Classification of Diseases and Injuries
2. Supplementary classification (V Codes and E Codes)
3. Appendices

Classification of Diseases and Injuries

Classification of Diseases and Injuries contains 17 chapters that classify condition
according to etiology and anatomical system.

EXAMPLE: Chapter 1, Infectious and Parasitic Diseases, represents classification
by etiology.
Chapter 9, Diseases of the Digestive System, represents anatomical
system.

Supplementary classification
ICD-9-CM has supplementary coding to classify events or circumstances. These are codes
but they do not reflect a diagnosis or injury. There are two supplementary classifications of
the ICD-9-CM:

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INFORMATION SHEET # 1

a. V Codes: V codes are the Supplementary Classification of Factors Influencing
Health Status and Contact with Health Services. This classification reports
circumstances other than disease or injury.

V01 Contact with or exposure to communicable diseases
V01.0 Cholera
Conditions classifiable to 001
V01.1 Tuberculosis
Conditions classifiable to 010-018
V01.2 Poliomyelitis
Conditions classifiable to 045

b. E codes: E codes are the Supplemental Classification of External Causes of
Injury and Poisoning. These codes classify environmental events and other
conditions as the cause of injury and other adverse effects.

E847 Accidents involving cable cars not running on rails
Accident to, on, or involving:
cable car, not on rails
ski chair-lift
ski-lift with gondola

Appendices
Appendices are used for specific coding purposes and specific types of facilities. For
example, Appendix A, Morphology of Neoplasms, lists the codes that are used to report
cancers in specialized cancer facilities.

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INFORMATION SHEET # 1

The Tabular List of Diseases and Injury

Chapter Titles Categories

1 Infectious and Parasitic Diseases 001–139
2 Neoplasms 140–239
3 Endocrine, Nutritional, and Metabolic Diseases and Immunity
Disorders 240–279
4 Diseases of the Blood and Blood-Forming Organs 280–289
5 Mental Disorders 290–319
6 Diseases of the Central Nervous System and Sense Organs 320–389
7 Diseases of the Circulatory System 390–459
8 Diseases of the Respiratory System 460–519
9 Diseases of the Digestive System 520–579
10 Diseases of the Genitourinary System 580–629
11 Complications of Pregnancy, Childbirth, and the Puerperium 630–677
12 Diseases of the Skin and Subcutaneous Tissue 680–709
13 Diseases of the Musculoskeletal System and Connective Tissue 710–739
14 Congenital Anomalies 740–759
15 Certain Conditions Originating in the Perinatal Period 760–779
16 Symptoms, Signs, and Ill-Defined Conditions 780–799
17 Injury and Poisoning 800–999

Supplementary Classifications

V Codes Supplementary Classification of Factors Influencing V01–V86
Health Status and Contact with Health Services E800–E999

E Codes Supplementary Classification of External Causes of Injury
and Poisoning

Appendixes

A Morphology of Neoplasms
B Glossary of Mental Disorders (deleted in 2004)
C Classification of Drugs by American Hospital Formulary Services
List
Number and Their ICD-9-CM Equivalents
D Classification of Industrial Accidents According to Agency
E List of Three-Digit Categories

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INFORMATION SHEET # 1

Volume 2: Alphabetic Index of Diseases and Injuries

There are three main sections in the alphabetic index:
1. Alphabetic Index of Diseases and Injuries
2. Table of Drugs and Chemicals
3. Alphabetic Index of External Causes of Diseases and Injuries (E Codes)

Alphabetic Index of Diseases and Injuries
The alphabetic index is organized by main terms, supplementary terms, and subterms.

Main Terms

Main terms are usually shown in bold prints. These terms represent diseases, injuries,
problems, complaints, and external causes of diseases or conditions.

EXAMPLE: Benign hypertension
Gastroesophageal reflux disease

Supplementary terms

Supplementary terms are usually shown in parentheses. These are terms that define the
main terms.

Subterms

Subterms describe body sites, etiology or clinical type. They are indented under the main
terms.

Supplementary term

Main term Rectocele

female (without uterine prolapse) 618.04

with uterine prolapse 618.4

Subterms complete 618.3
incomplete 618.2

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INFORMATION SHEET # 1

Volume 3: Tabular List and Alphabetic Index of Procedures

There are two sections in Volume 3:
1. Alphabetic Index
2. Tabular List

Alphabetic Index
The Alphabetic Index of Procedures contains an alphabetic list of procedure, eponym and
operation.

Tabular List
The format of the tabular list resembles the format of Volume 1. It contains three or four
digits placed before the procedure type.

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LEARNING EXERCISES 1.3

Using the Alphabetic Index, underline the main term in each of the following:
1. Cerebral thrombosis
2. Inguinal hernia
3. Breast mass
4. Hypertensive nephropathy
5. Chronic obstructive pulmonary disease

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INFORMATION SHEET # 1

ICD-9-CM Conventions

ICD-9-CM uses conventions as a guide to help coders in assigning diagnostic and/or
procedural codes as accurately as possible. There are several conventions in the ICD-9-
CM.

1. Format
The ICD-9-CM uses an indented format for ease in reference.

2. Abbreviations

NEC “Not elsewhere classifiable”
This abbreviation in the index represents “other specified” means that ICD-9-
CM does not have an available code for the documented condition.

NOS “Not otherwise specified”
This abbreviation is the equivalent of unspecified. This is used in the Tabular
List

3. Punctuation

[ ] Brackets are used in the tabular and index list. These are used to enclose
synonyms, alternative wording or explanatory phrases.

( ) Parentheses are used in both the index and tabular to enclose supplementary
words

: Colons are used in the Tabular List after an incomplete term that needs one
or more of modifiers following the modifiers that follow it.

4. Includes and Excludes Notes

Includes These notes are seen under a three-digit code title. This is to further
define the contents of the code.

EXAMPLE: Carcinoma in situ (230-234)
Includes:
Bowen’s disease
erythroplasia
Queyrat’s erythroplasia

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INFORMATION SHEET # 1

Excludes These notes are seen in the Tabular List of Disease and Injuries and
the Tabular List of Procedures. Excludes notes indicate the terms
excluded from the code are to be coded elsewhere.

EXAMPLE: 392 Rheumatic chorea
Excludes:
chorea:
NOS (333.5)
Huntington’s (333.4)

5. Other and Unspecified codes
a. “Other” codes
This is used when the information in the medical record gives detail for which
the code does not exist.

b. “Unspecified” codes
These codes are used when the information in the medical record is
insufficient to assign a more specific code.

6. “Code first underlying disease” “Use Additional Codes”

a. “Code first underlying disease”
This code is located in the Tabular List with codes that are not intended to be
selected as a primary disease because they are manifestation of other
underlying diseases.

EXAMPLE: 585 Chronic kidney disease (CKD)
Includes:
Chronic uremia
Code first hypertensive chronic disease, if applicable

(403.00-403.91, 404.00-404.93)

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INFORMATION SHEET # 1

b. “Use Additional Codes”
This note instructs the coder to code further information.

EXAMPLE: 686 Other local infection of skin and subcutaneous tissue
Use additional code to identify any infectious organism (041.0-041.8)

7. “And”
The word “and” would mean “and” or “or” when it appears in a title.

8. “With”
The word “with” in the alphabetic index immediately follows the main term.

9. “See” and “See Also” (Cross-reference notes)
a. “See”
The word “see” directs the coder to another main term in which all the information of
a disease or injury can be found.

EXAMPLE: Prosthetic implant, see Complications, mechanical

b. “See Also”
The word “See Also” instructs the coder that a main term in the index should be
referenced.

EXAMPLE: sesamoid, joint (see also Loose, body, joint) 718.1

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INFORMATION SHEET # 1

ICD-9-CM GENERAL CODING GUIDELINES

1. Use of Both Alphabetic Index and Tabular List
Use both the Alphabetic Index and the Tabular List when locating and assigning
code.

2. Locate each term in the Alphabetic Index
Locate each term in the Alphabetic Index and verify the code selected in the Tabular
list.

3. Level of Detail in Coding
Diagnosis and procedure codes are to be used at their highest number of
digits available.

4. Code or codes from 001.0 through V89.09
The appropriate code or codes from 001.0 through V89.09 must be used to identify
diagnoses, symptoms, conditions, problems, complaints, or other reason (s) for the
encounter/visit.

5. Selection of codes from 001.0 through 999.9
The selection of codes 001.0 through 999.9 will frequently be used to describe the
reason for the admission/encounter.

6. Signs and symptoms
Codes that describe signs and symptoms, as opposed to diagnoses, are acceptable
for reporting purposes. This is done when the doctor has not provided any
diagnosis. Chapter 16 of ICD-9-CM, Symptoms, Signs and Ill-defined conditions
(codes 780.0-799.9) contains main but not all codes for symptoms.

7. Conditions that are integral part of a disease process
Signs and symptoms that are associated routinely with a disease process should not
be assigned as additional codes, unless otherwise specified by the classification.

8 Conditions that are not an integral part of a disease process
Additional signs and symptoms not associated with a disease process should not be
coded.

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INFORMATION SHEET # 1

9 Multiple coding for a single condition
There are other conditions that require more than one code. “Use additional code”
notes are found in the tabular at codes that are not part of an etiology/manifestation
where a secondary code is useful to fully describe a condition.

10. Acute and chronic conditions

If the same condition is described as both acute (subacute) and chronic, and
separate subentries exist in the Alphabetic Index at the same indentation level, code
both. Sequence the acute (subacute) code first.

11. Combination Code

This is a single code used to classify two diagnoses or:
a. A diagnosis with an associated secondary process.
b. A diagnosis with associated complication

12. Late Effects

A late effect is the residual effect after the acute phase of an illness of injury has
terminated.

13. Impending or Threatened Condition
Code any condition described at the time of discharge as “impending” or threatened
as follows:
a. If it did occur, code as confirmed diagnosis.
b. If it did not occur, reference the Alphabetic Index to determine if the
condition has a subentry term for “impending” or “threatened” and also
reference main term entries for “Impending” and for “Threatened.”
c. If the subterms are listed, assign the given code.
d. If the subterms are not list, code the existing underlying condition (s)
and not the condition described as impending or threatened.

14. Reporting Same Diagnosis Code More than Once

Each unique ICD-9-CM diagnosis code may be reported only once for an encounter.
This applies to bilateral conditions or two different conditions classified to the same
ICD-9-CM diagnosis code.

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INFORMATION SHEET # 1

15. Admissions/Encounters for Rehabilitation

When the purpose for the admission/encounter is rehabilitation, sequence the
appropriate V code from category V57, Care involving the use of rehabilitation
procedures, as the principal/first-listed diagnosis. The code for the condition for
which the service is being performed should be reported as an additional diagnosis.

16. Documentation for BMI and Pressure Ulcer Stages

For the Body Mass Index (BMI) and pressure ulcer stage codes, code assignment
may be based on medical record documentation from clinicians who are not the
patient’s provider (i.e., physician or other qualified healthcare practitioner legally
accountable for establishing the patient’s diagnosis), since this information is
typically documented by other clinicians involved in the care of the patient (e.g., a
dietitian often documents the BMI and nurses often documents the pressure ulcer
stages)

The BMI and pressure ulcer codes should only be reported as secondary diagnoses.

17. Syndromes

Follow the Alphabetic Index guidance when coding syndromes. In the absence of
index guidance, assign codes for the documented manifestations of the syndrome.

ICD-9-CM BASIC CODING STEPS

1. Identify all the main terms included in the diagnostic statement.
For example, Hailey is a 7-month-old who has been pulling his ears.
He has had a bad cough.
Diagnosis: Viral bronchitis.
Hailey’s diagnosis is viral bronchitis. In this case, the main term is
bronchitis.

2. Locate each term in the Alphabetic Index.

3. Refer to any subterms.
After locating the main term in the Alphabetic Index, find descriptive words to
make it more specific.
For example, in Hailey’s condition, the subterm is viral. In this case, the
tentative correct code is 466.0.

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INFORMATION SHEET # 1

4. Follow cross-reference instructions if the needed code is not located
under the first main entry consulted.

5. Locate the code in the Tabular List.
Look for the code number in the Tabular List to verify if this is the correct
code.
In Hailey’s case, locate 466.0 in the Tabular list.

6. Read all information to get the code that corresponds to the patient’s
disease or condition. Look for any fourth- or fifth-code requirements
and exclusions.
Note that in Hailey’s case, no fourth- or fifth-code is needed so the correct
code is 466.0.

7. Continue coding the diagnostic statement until all the components are
fully identified.

COMPUTER-AIDED CODING

Many large healthcare facilities use computer programs to assign ICD-9-CM codes. This is
based on the logic behind selecting codes on a computerized version of the actual ICD-9-
CM codebook.

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LEARNING EXERCISES 1.4

Using the instructions and conventions discussed, assign the appropriate codes to the
following:
1. Acute mastoiditis
2. Pustular facial acne
3. Unstable angina
4. Paroxysmal tachycardia
5. Hypertensive cardiomegaly

Resources:

http://highered.mcgraw-hill.com/sites/dl/free/0073401854/568467/JurekSampleCH2.pdf
http://www.ama-assn.org/resources/doc/cpt/icd9cm_coding_guidelines_08_09_full.pdf

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OPERATION SHEET #1

Operation Title: Assigning codes for diagnoses
Purpose:
Materials: To be able to assign the correct diagnoses codes using
Procedure: the ICD-9-CM coding system.

Quality Criteria: 1. ICD-9-CM Manual
2. Medical dictionaries
3. Mockup/Sample medical documentation
4. Computer with internet connection

1. Identify all the main terms included in the diagnostic
statement.

2. Locate each term in the Alphabetic Index.
3. Refer to any subterms.
4. Follow cross-reference instructions if the needed code

is not located under the first main entry consulted.
5. Locate the code in the Tabular List.
6. Read all information to get the code that corresponds

to the patient’s disease or condition.
7. Look for any fourth- or fifth-code requirements and

exclusions.
8. Continue coding the diagnostic statement until all the

components are fully identified.

1. Familiarity on the ICD-9-CM manual.
2. Validity of the assigned codes must be double

checked.

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ASSIGNMENT SHEET # 1

Objective: To be able to assign diagnosis codes using the ICD-9-CM manual.
Students are asked to:
1. Browse on the different volumes of the ICD-9-CM manual.
2. Using the medical dictionary, pick at least 5 medical terms. Identify the main
term/s and give the appropriate code using the guidelines and conventions of
the ICD-9-CM manual.

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SELF-CHECK #1

LO1. Assign diagnoses codes

Directions:

A. Without referring to the Alphabetic Index of Diseases, underline the word or words
that indicate the main term for each diagnosis.

1. Acute myocardial infarction
2. Bunion, left great toe
3. Urinary tract infection due to E. coli.
4. Cerebrovascular disease
5. Chronic tonsillar hypertrophy

B. Code the following diagnoses:

1. Mitral insufficiency, congenital
2. Chronic aortic and mitral valve insufficiency, rheumatic, with acute congestive

heart failure
3. Left heart failure with benign hypertension
4. Hypertensive nephropathy, benign
5. Congestive heart failure due to hypertension

C. Locate the diagnosis or diagnoses in the following medical reports, underline the
main term(s), and give the appropriate codes for each.

Report #1:

TIME SEEN: The patient is initially seen at XXXX hours.

HISTORY OF PRESENT ILLNESS: The patient is a 7-month-old who has been
pulling his ears. He has had a bad cough. Has been screaming, coughing,
sneezing, with nasal congestion. Question of sore throat today. Cough and rattles
but no phlegm production. No wheezing or shortness of breath. This started three
days ago. He is followed by Dr. Doe. No daycare. No fever or chills. No other
associated symptoms. No history of otitis.

PAST MEDICAL HISTORY: None.

ALLERGIES: None.

MEDICATIONS: None.

PAST SURGICAL HISTORY: None.

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SOCIAL HISTORY: No secondhand smoke in the house. Lives with mother who is
well but has a cold.

REVIEW OF SYSTEMS: No fever or chills. Eyes have been normal. No chest pain,
abdominal pain. No nausea, vomiting, diarrhea. No GU or GYN symptoms. No joint
or muscle swelling, redness or pain. No hives, itching or rashes. No confusion,
vertigo, weakness, seizures.

PHYSICAL EXAMINATION: Pulse 24, temperature 96 axillary, weight 7.9 kilos,
respirations 42, SiO2 100% on room air.

A 7-month-old who is alert. Has boggy nose. TMs are normal. Neck is supple.
Fontanelle is open, flat, soft. Neck: No increased cervical nodes. Lungs are clear.
Heart has regular rate and rhythm. No murmur. Abdomen is soft, benign. No CVA
tenderness. Oropharynx is negative including the epiglottis. No exudate or
erythema.

HOSPITAL COURSE: No intervention produced any measurable benefit. He has a
URI, vital bronchitis which is not requiring antibiotics. Mother will watch for fever of
102. Recheck his course. Follow with Dr. Doe. Vital signs felt stable for discharge
home.

DIAGNOSES:
1. Viral bronchitis.
2. Otitis media.

Report # 2:

Subjective: The patient is in today for hospital followup. He ended up being hospitalized
shortly after I saw him last time for acute renal failure secondary to an E. coli UTI. He was
starting to have chills and shivers and a little bit of confusion and a lot of fatigue and
shortness of breath, so his wife brought him to the ER where they diagnosed the problem.
There, he was seen by the nephrologist who is already consulting on his case. He was
started on appropriate antibiotics and was in the hospital about 5 days before his discharge.
There were no changes to his medications other than the addition of the antibiotic that he
was discharged on. He is complaining of increased fatigue over where he was before.
There was a set of postdischarge labs that were done about 2 weeks ago and those
showed his potassium to be mildly elevated at 5.3. His creatinine was still up to 2.3. He is
denying any swelling. Weight is fairly stable. His blood sugar logs show his blood sugars
to range from about 67 to up to 200s, mostly in the low to mid 100s. Certainly, not allowing
enough room to increase his Lantus dose as he does at least 2 or 3 times a week of blood
sugars in the 60s and 70s. He and his wife both readily admit that a lot of the variability of
his blood sugars is related to the variability of his diet. He does not have a whole lot of
energy to be exercising or walking. Also, his right knee and hip seemed to bother him a fair
amount. He does take his Tylenol or Darvocet as needed. No chest pain and no shortness
of breath. No cough, no nasal congestion.

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Objective: His exam today was fairly benign. His lungs are clear in all fields. His heart
had a regular rate and rhythm with a muffled heart sound. No peripheral edema. Abdomen
is soft and nontender. We did review his labs from the hospital and there was some mild
chronic anemia there in addition to the acute renal failure. No real studies were done for
the anemia so that I am going to go ahead and check a CBC, iron studies, folate, B12. I am
also going to check a testosterone. He has not had a PSA done in a while. TSH,
comprehensive metabolic profile.

Assessment:
1. Urinary tract infection.
2. Dehydration.
3. Diabetes mellitus.

Plan: We will call him regarding the results. I advised him that a few of these values will
be sent out so I am going to have those for 2 or 3 days but certainly if his electrolytes or
anything coming back is significantly abnormal, we will give him a call as soon as we get
those abnormal labs. Otherwise, we will call once we have everything in. I would plan to
see the patient back again in 1 month. We will order labs at that time as indicated.

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ANSWER KEY #1

LO1. Assign diagnoses codes

LEARNING EXERCISES 1.1

1. The prefix meaning surrounding is peri
inter intra peri

2. Pain which can only be observed by the patient is symptom.
sign symptom prognosis

3. It is a word that is placed at the end of the root word. prefix

combining form suffix prefix

4. A disease named after the person who discovered it. eponym

eponym abbreviation acronym

5. A localized response to injury. inflammation

Inflammation infection disease

6. These are called the base word. root words

combining form root words suffix

7. Divide the medical term gastroduodenoscopy into the combining form, root word and

suffix.

suffix: -scopy an instrument for viewing

root word: duodeno- relating to the duodenum

combining form gastro relating to the stomach

Gastroduodenoscopy is the visualization of the stomach and duodenum

LEARNING EXERCISES 1.2

Identify the following purpose of ICD-9-CM coding in the following cases as Research (R),
Quality (Q), Communication (C), Reimbursement (RM), or Administrative (A)

1. A pharmaceutical company wants to know if their new drug is effective. __R__
2. A hospital board would like a vaccination campaign because of a reduction in services

to patients over the last year. __A__
3. A wrong set of codes was sent to an insurance company resulting in incorrect billing

and reimbursement and a new set of codes had to be resubmitted. __RM__
4. A hospital asked the patients who underwent knee surgery to complete a survey to

determine if their services were satisfactory. __Q__
5. A patient wanted to know the coverage policy of his insurance. __C__

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LEARNING EXERCISES 1.3

Using the Alphabetic Index, underline the main term in each of the following:
1. Cerebral thrombosis
2. Inguinal hernia
3. Breast mass
4. Hypertensive nephropathy
5. Chronic obstructive pulmonary disease

LEARNING EXERCISES 1.4

Using the instructions and conventions discussed, assign the appropriate codes to the
following:

1. Acute mastoiditis 383.00
2. Pustular facial acne 706.1
3. Unstable angina 411.1
4. Paroxysmal tachycardia 427.2
5. Hypertensive cardiomegaly 402.90

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SELF-CHECK #1 ANSWERS

Directions:

A. Without referring to the Alphabetic Index of Diseases, underline the word or words
that indicate the main term for each diagnosis.

1. Acute myocardial infarction
2. Bunion, left great toe
3. Urinary tract infection due to E. coli
4. Cerebrovascular disease
5. Chronic tonsillar hypertrophy

B. Code the following diagnoses:

1. Mitral insufficiency, congenital 746.6
2. Chronic aortic and mitral valve insufficiency, rheumatic, with acute congestive

heart failure 398.91 + 396.3
3. Left heart failure with benign hypertension 428.1 + 401.1
4. Hypertensive nephropathy, benign 403.10
5. Congestive heart failure due to hypertension 402.91 + 428.0

C. Locate the diagnosis or diagnoses in the following medical reports, underline the
main term(s), and give the appropriate codes for each.

Report #1:

TIME SEEN: The patient is initially seen at XXXX hours.

HISTORY OF PRESENT ILLNESS: The patient is a 7-month-old who has been
pulling his ears. He has had a bad cough. Has been screaming, coughing,
sneezing, with nasal congestion. Question of sore throat today. Cough and rattles
but no phlegm production. No wheezing or shortness of breath. This started three
days ago. He is followed by Dr. Doe. No daycare. No fever or chills. No other
associated symptoms. No history of otitis.

PAST MEDICAL HISTORY: None.

ALLERGIES: None.

MEDICATIONS: None.

PAST SURGICAL HISTORY: None.

SOCIAL HISTORY: No secondhand smoke in the house. Lives with mother who is
well but has a cold.

REVIEW OF SYSTEMS: No fever or chills. Eyes have been normal. No chest pain,
abdominal pain. No nausea, vomiting, diarrhea. No GU or GYN symptoms. No joint

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or muscle swelling, redness or pain. No hives, itching or rashes. No confusion,
vertigo, weakness, seizures.

PHYSICAL EXAMINATION: Pulse 24, temperature 96 axillary, weight 7.9 kilos,
respirations 42, SiO2 100% on room air.

A 7-month-old who is alert. Has boggy nose. TMs are normal. Neck is supple.
Fontanelle is open, flat, soft. Neck: No increased cervical nodes. Lungs are clear.
Heart has regular rate and rhythm. No murmur. Abdomen is soft, benign. No CVA
tenderness. Oropharynx is negative including the epiglottis. No exudate or
erythema.

HOSPITAL COURSE: No intervention produced any measurable benefit. He has a
URI, vital bronchitis which is not requiring antibiotics. Mother will watch for fever of
102. Recheck his course. Follow with Dr. Doe. Vital signs felt stable for discharge
home.

DIAGNOSES:
1. Viral bronchitis. __466.0___
2. Otitis media. __382.9___

Report # 2:

Subjective: The patient is in today for hospital followup. He ended up being hospitalized
shortly after I saw him last time for acute renal failure secondary to an E. coli UTI. He was
starting to have chills and shivers and a little bit of confusion and a lot of fatigue and
shortness of breath, so his wife brought him to the ER where they diagnosed the problem.
There, he was seen by the nephrologist who is already consulting on his case. He was
started on appropriate antibiotics and was in the hospital about 5 days before his discharge.
There were no changes to his medications other than the addition of the antibiotic that he
was discharged on. He is complaining of increased fatigue over where he was before.
There was a set of postdischarge labs that were done about 2 weeks ago and those
showed his potassium to be mildly elevated at 5.3. His creatinine was still up to 2.3. He is
denying any swelling. Weight is fairly stable. His blood sugar logs show his blood sugars
to range from about 67 to up to 200s, mostly in the low to mid 100s. Certainly, not allowing
enough room to increase his Lantus dose as he does at least 2 or 3 times a week of blood
sugars in the 60s and 70s. He and his wife both readily admit that a lot of the variability of
his blood sugars is related to the variability of his diet. He does not have a whole lot of
energy to be exercising or walking. Also, his right knee and hip seemed to bother him a fair
amount. He does take his Tylenol or Darvocet as needed. No chest pain and no shortness
of breath. No cough, no nasal congestion.

Objective: His exam today was fairly benign. His lungs are clear in all fields. His heart
had a regular rate and rhythm with a muffled heart sound. No peripheral edema. Abdomen
is soft and nontender. We did review his labs from the hospital and there was some mild
chronic anemia there in addition to the acute renal failure. No real studies were done for
the anemia so that I am going to go ahead and check a CBC, iron studies, folate, B12. I am
also going to check a testosterone. He has not had a PSA done in a while. TSH,
comprehensive metabolic profile.

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March 2012 48

Assessment:
1. Urinary tract infection. 599.0
2. Dehydration. 276.51
3. Diabetes mellitus. 250.0

Plan: We will call him regarding the results. I advised him that a few of these values will
be sent out so I am going to have those for 2 or 3 days but certainly if his electrolytes or
anything coming back is significantly abnormal, we will give him a call as soon as we get
those abnormal labs. Otherwise, we will call once we have everything in. I would plan to
see the patient back again in 1 month. We will order labs at that time as indicated.

Code No. Assigning Medical Claims Date: Developed Date: Revised Page #

March 2012 49