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If you need to have a strong understanding of how ICD-9-CM diagnosis and procedure codes are determined, then you have chosen the right book, ICD-9-CM Inpatient Coding Reference and Study Guide. The author designed a book that goes beyond the fundamentals, that gets into the details of ICD-9-CM diagnosis and procedure code assignment as would be experienced on the job. This user-friendly reference teaches coders how to handle many coding situations, while also being comprehensive enough to teach someone with a basic knowledge of medical coding how to move to the next level of advanced inpatient coding. Updated every year to reflect the annual ICD-9-CM coding changes, the text enables HIM professionals to master the concepts of medical coding while also gaining critical knowledge to pass the CCS exam administered by AHIMA and the CPC-H exam from the AAPC. The book also serves as an excellent desk reference and resource for coders who need to refresh their ICD-9-CM coding skills. Among the topics covered in Volume 1 are inpatient coding guidelines, coding conventions, coding tables, and a drug reference. However, the heart of this manual is the body system analysis, based on chapters 1 - 17 of the Tabular list in Volume I of the ICD-9-CM Official Coding Guidelines. The chapters are categorized by body system such as respiratory, digestive, et al. The chapters in this study guide follow the same sequence as the Official Coding Guidelines. All chapters, in addition to highlighting basic coding guidelines, contain situation-based coding tips and coding examples. A quiz follows each chapter reinforcing concepts in a rigorous manner that applies directly to the professional coding environment. The book also contains a selective discussion of invasive procedures that the coder will most likely encounter on the job and on the exam. At the end of ICD-9-CM Inpatient Coding Reference and Study Guide are 15 case studies, providing the reader with an opportunity to assess their ICD-9-CM coding skill set and speed at coding inpatient medical records. Each record contains a face sheet, history & physical, progress notes, and answer sheet. Some of the case studies contain ER reports, consultations, as well as operative and pathology reports. The answer key at the end of this study guide contains a rationale for all code assignments. 456 short answer questions 116 multiple choice questions 15 full medical record case studies Each question is highly relevant and reflects a coding situation most hospital-based inpatient coders will face. The text strives to ensure the reader understands every diagnosis and procedure discussed: thorough discussion of symptoms, standard treatment protocols, and medications. Coding examples and quizzes help clarify the information presented. Linda Kobayashi, BA, RHIT, CCS, has been a coder and coding manager for almost 20 years. Since 1998, Ms. Kobayashi has owned and operated Codebusters, Inc., a nationwide coding consulting company. Widely regarded as a medical coding and auditing expert, she has conducted workshops on a variety of coding topics, including CCS Exam preparation workshops. Throughout her career the author has remained professionally active, as an AHIMA member as well as a member of her state association, CHIA (California health Information Association). Her formal training includes a teaching credential from California State University Los Angeles, a B.A. degree in English Literature from University of California Los Angeles, an RHIT from AHIMA after completing the RHIT program at East Los Angeles College, and a CCS certificate from AHIMA. Extensive experience as a hands-on coder, auditor and educator, and has given the author the expertise to help coders prepare for the professional coding environment.
This book trains the next generation of scientists representing different disciplines to leverage the data generated during routine patient care. It formulates a more complete lexicon of evidence-based recommendations and support shared, ethical decision making by doctors with their patients. Diagnostic and therapeutic technologies continue to evolve rapidly, and both individual practitioners and clinical teams face increasingly complex ethical decisions. Unfortunately, the current state of medical knowledge does not provide the guidance to make the majority of clinical decisions on the basis of evidence. The present research infrastructure is inefficient and frequently produces unreliable results that cannot be replicated. Even randomized controlled trials (RCTs), the traditional gold standards of the research reliability hierarchy, are not without limitations. They can be costly, labor intensive, and slow, and can return results that are seldom generalizable to every patient population. Furthermore, many pertinent but unresolved clinical and medical systems issues do not seem to have attracted the interest of the research enterprise, which has come to focus instead on cellular and molecular investigations and single-agent (e.g., a drug or device) effects. For clinicians, the end result is a bit of a “data desert” when it comes to making decisions. The new research infrastructure proposed in this book will help the medical profession to make ethically sound and well informed decisions for their patients.
These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
Learn to code effectively with ICD-9-CM medical coding and gain a thorough introduction to ICD-10-CM/PCS coding with one book! ICD-9-CM Coding, 2013/2014 Edition combines basic coding principles with proven, practical insight and the ICD-9-CM and ICD-10-CM/ICD-10-PCS Official Guidelines for Coding and Reporting to prepare you for the upcoming implementation of ICD-10-CM/PCS. Whether you're learning to code for the first time or making the transition from ICD-9-CM to ICD-10-CM/PCS, leading medical coding authors Karla Lovaasen and Jennifer Schwerdtfeger deliver the fundamental understanding you need to succeed in hospital and physician settings. Both ICD-9-CM codes and ICD-10-CM/ICD-10-PCS codes are shown in all coding exercises and examples (including answer keys). Emphasis on ICD-10-CM and ICD-10-PCS coding prepares you for the upcoming implementation of ICD-10. MS-DRG documentation and reimbursement details guide you through this key component of the coding process. Line coding exercises and activities challenge you to apply concepts to solve problems. ICD-10 Official Guidelines for Coding and Reporting (OGCR) are included in each coding chapter, immediately following the ICD-9-CM coding guidelines. Full-color A&P content, disease coverage, procedure guidelines, and drug data ensure that you’re familiar with key topics affecting medical coding. Medical record coverage introduces the records and documents you’ll encounter on the job. Updated Coding Clinic references direct you to the definitive coding resource from the American Hospital Association (AHA). A companion Evolve website provides convenient online access to the OGCR, medical and surgical root operations definitions, a MS-DRG list, partial answer keys, and more.
- Codingupdates.com companion website includes ICD-9-CM coding updates, an ICD-9-CM to ICD-10-CM crosswalk, and MS-DRG information.
- UPDATED Coding Clinic® citations provide official ICD-9-CM coding advice, ensuring accurate coding by identifying the year, quarter, and page number for information about specific codes in the AHA's Coding Clinic for ICD-9-CM. - UPDATED age edits from the Medicare Code Editor ensure that you have the latest information needed for accurate coding.