CGS Health Information Technology Programs: Call 704-254-7900: February 2011

How Should CAD be Coded?

Coding Clinic (1997, Q2)

Question: A patient has coronary artery disease. There is no mention of a past history of CABG. Should this be coded 414.00 Coronary atherosclerosis of unspecified type of vessel, native or graft, or 414.01 Coronary atherosclerosis of native coronary artery?

Answer: Assign code 414.01, coronary atherosclerosis of native coronary artery. Since there is no history of CABG, this is a native coronary vessel. However, if the documentation is unclear concerning prior bypass surgery, query the physician.

How should Hypertensive Retinopathy be Coded?

Two codes are necessary to identify the condition. First assign the code from subcategory 362.11, Hypertensive retinopathy, then the appropriate code from categories 401-405 to indicate the type of hypertension.

See ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2010 http://www.cdc.gov/nchs/data/icd9/icdguide10.pdf

How should Acute Bronchitis and COPD be Coded?

According to the ICD-9-CM Official Guidelines for Coding and Reporting effective October 1, 2010:

Acute bronchitis, code 466.0, is due to an infectious organism. When acute bronchitis is documented with COPD, code 491.22, Obstructive chronic bronchitis with acute bronchitis, should be assigned. It is not necessary to also assign code 466.0. If a medical record documents acute bronchitis with COPD with acute exacerbation, only code 491.22 should be assigned. The acute bronchitis included in code 491.22 supersedes the acute exacerbation. If a medical record documents COPD with acute exacerbation without mention of acute bronchitis, only code 491.21 should be assigned. See the link provided to get a full copy of the ICD-9-CM Official Guidelines for Coding and Reporting. http://www.cdc.gov/nchs/data/icd9/icdguide10.pdf

How Should You Code Anemia Associated with Malignancy?

The official ICD-9-CM guidelines for Coding and Reporting (Effective 10/1/2010) states

"When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate anemia code (such as 285.22) is designated as the principal diagnosis and is followed by the appropriate codes for the malignancy. Code 285.22 may also be used as a secondary code if the patient suffers from anemia and is being treated for the malignancy.

How to Code HIV

Code HIV or HIV related illness only if it is confirmed in the medical record or in a diagnostic statement.
042 should be coded for HIV or related illnesses

V08 should be coded for HIV patients with an asymptomatic status

795.71 is for nonspecific HIV serology.

Remember once the patient has an HIV diagnosis, you can not use V08.

To learn more about HIV click on the link below:
http://www.mayoclinic.com/health/hiv-aids/DS00005

Reference section 1.c.1.a,d,e Human Immunodeficiency Virus (ICD9 Manual)

Is this Career for You?

If you search google for medical billing and coding, you will find a host of schools that offer training. If you call, you will be encouraged to sign up for class. Of course, that is normal. However, you need to determine if this career is for you. I mean, you need to REALLY be sure.

Ponder over the following personality traits:

1. Independent: Can you complete tasks without direction? Do you have to be encouraged constantly. Many billers and coders have assignments and they are expected to complete them within a specific time frame.

2. Decision maker: Can you make logical decisions? Do you constantly need to consult with others prior to deciding what should be done?

3. Detail oriented: Do you pay attention to the little things? Are you capable of looking for trends?

4. Organizational skills: You must be organized. You will handle a variety of forms and important documents.

5. Computer literate: Do you know how to use a computer? The basics: attach documents, use word, and etc

Earn your CPC credentials in just 5 months with CGS Billing Service

Become a professional medical coder in just 5 months and save thousands of dollars with CGS Billing Service. Some colleges and other institutions charge $17,000 or more for coding certification. CGS Billing Services offers better classes for $4433.00. This includes tuition, books, and an opportunity to take the CPC exam twice! If you are interested in earning your coding credentials through a well known and respected company, consider CGS Billing Service. You can earn coding credentials from the AAPC (American Academy of Professional Coders) with a little guidance. Please scroll down this screen. Make an appointment today! We will be happy to assess your needs.