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2011

CPC Certification Study Guide

Deborah Grider G. John Verhovshek

CPC® 2011 Certification Study Guide

Authors: Deborah Grider, CPC, CPC-I, CPC-H CPC-P, COBGC, CPMA, CPCD, CCS-P G. John Verhovshek, MA, CPC With the Assistance of: Katherine Abel, CPC, CPMA, CPC-I, CRMS 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, 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 Raemarie Jimenez, CPC, CPMA, CPC-I CANPC, CRHC Betty Johnson, CPC, CPC-H, CPC-I, CPCD Dolly Perrine, CPC, CPMA, CPC-I, CUC Jean Pryor, CPC, CPMA, CPC-I, CIMC Dorothy Steed, CPC-H, CPMA, CPC-I, CEMC, CFPC Kate Tierney, CPC, CPC-P, CEDC, CEMC, CGSC, COBGC Susan Ward, CPC, CPC-H, CPC-I, CEMC, CPCD, CPRC Reviewers: Lynn Anderanin, CPC, CPC-I, COSC Nicole Benjamin, CPC, CPC-I, CEDC Jennifer Hume, CPC, CPMA, CEMC Lindsay-Anne Jenkins, CPC, CPC-H, CIRCC, CPC-I Vandna Kejariwal, CPC, CPC-H, 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, CHI Carrie Severson, CPC, CPC-H, CPC-P, CPMA, CPC-I Kathy Skolnick, CPC, CPC-I Charleen Yamasato, CPC, CPC-I Production: Dianne Allred, Designer, Desktop Publisher Renee Dustman, Copy Editor Tina M. Smith, Desktop Publisher

© 2011, 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: 111-1-54484-0 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 100,000 members representing physician offices, outpatient facilities, and payer environments. AAPC certifications validate the knowledge and expertise of health care professionals in disciplines including medical coding, auditing and compliance. AAPC offers the industry-leading Certified Professional Coder (CPC®) and Certified Professional Medical Auditor (CPMA®) credentials, along with more than 20 specialty-specific coding credentials. AAPC also provides a wide variety of continuing education, resources and networking opportunities.

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2011 CPC Certification Study Guide

CPT ® copyright 2010 American Medical Association. All rights reserved.

Contents

Chapter 1 The Business of Medicine . . . . . . . . . . . . . . . . . . . . . 1

Coding as a Profession . . . . . . . . . . . . . . . . . . . . .1 The Hierarchy of Providers . . . . . . . . . . . . . . . . .1 The Different Types of Payers . . . . . . . . . . . . . . .1 Understanding RBRVS . . . . . . . . . . . . . . . . . . . .2 Medical Necessity . . . . . . . . . . . . . . . . . . . . . . . . .4 The Need for Privacy and Security . . . . . . . . . .5 Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . .6 The Need for Compliance Rules and Audits . . . . . . . . . . . . . . . . . . . . . . . . . .6 The OIG Work Plan . . . . . . . . . . . . . . . . . . . . . . .7 What AAPC Will Do for You . . . . . . . . . . . . . . .8

Chapter 4 Introduction to CPT®, Surgery Guidelines, HCPCS Level II, and Modifiers . . . . 63

Introduction to CPT® . . . . . . . . . . . . . . . . . . . .63 National Correct Coding Initiative (NCCI) . . . . . . . . . . . . . . . . .67 Sequencing CPT® Codes . . . . . . . . . . . . . . . . . . .68 CPT® Assistant . . . . . . . . . . . . . . . . . . . . . . . . . . .69 CPT® Category II Codes and a Brief Overview of the Physician Quality Reporting Initiative . . . . . . . . . . . . . .69 CPT® Category III Codes . . . . . . . . . . . . . . . . . .69 CPT® Appendices . . . . . . . . . . . . . . . . . . . . . . . .70 Surgery Guidelines . . . . . . . . . . . . . . . . . . . . . . .71 HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . . .73 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

Chapter 2 Terminology and Anatomy Review . . . . . . . . . . . 13

Medical Terminology . . . . . . . . . . . . . . . . . . . .13 Integumentary System . . . . . . . . . . . . . . . . . . . .17 Musculoskeletal System . . . . . . . . . . . . . . . . . . .19 Cardiovascular System . . . . . . . . . . . . . . . . . . .21 Lymphatic System . . . . . . . . . . . . . . . . . . . . . . . .24 Respiratory System (Pulmonary System) . . . .26 Digestive System . . . . . . . . . . . . . . . . . . . . . . . . .27 Urinary System . . . . . . . . . . . . . . . . . . . . . . . . . .28 Reproductive Systems . . . . . . . . . . . . . . . . . . . .28 Nervous System . . . . . . . . . . . . . . . . . . . . . . . . .29 Endocrine System . . . . . . . . . . . . . . . . . . . . . . . .30 Hematologic (Hemic) System . . . . . . . . . . . . . .31 Immune System . . . . . . . . . . . . . . . . . . . . . . . . .31

Chapter Integumentary System . . . . . . . . . . . . . . . . . . . . . . . 85

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . .85 Anatomy and Medical Terminology . . . . . . . .86 ICD-9-CM Coding . . . . . . . . . . . . . . . . . . . . . .86 CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96

Chapter 6 Musculoskeletal System . . . . . . . . . . . . . . . . . . . . . 101

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . .101 Anatomy and Medical Terminology . . . . . . .101 ICD-9-CM Coding . . . . . . . . . . . . . . . . . . . . . .106 CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . .108 HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . .111 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111

Chapter 3 Introduction to ICD-9-CM . . . . . . . . . . . . . . . . . . . 35

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Overview of ICD-9-CM layout . . . . . . . . . . . . .35 Steps to Look Up a Diagnosis Code . . . . . . . . .40 ICD-9-CM Official Guidelines for Coding and Reporting . . . . . . . . . . . . . . . . . . . .41 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

Chapter 7 Respiratory, Hemic, Lymphatic, Mediastinum, and Diaphragm . . . . . . . . . . . . . . . 117

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . .117 Anatomy and Medical Terminology . . . . . . .117 ICD-9-CM Coding . . . . . . . . . . . . . . . . . . . . . .119 CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . .121 HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . .127

CPT ® copyright 2010 American Medical Association. All rights reserved.

2011 CPC Certification Study Guide

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Contents

Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127

Chapter 12 Endocrine and Nervous System . . . . . . . . . . . . . 201

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . .201 Anatomy and Medical Terminology . . . . . . .201 ICD-9-CM Coding . . . . . . . . . . . . . . . . . . . . . 205 CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . 207 HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . .215 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .215 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217

Chapter 8 Cardiovascular System . . . . . . . . . . . . . . . . . . . . . 133

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . .133 Anatomy and Medical Terminology . . . . . . .133 ICD-9-CM Coding . . . . . . . . . . . . . . . . . . . . . .135 CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . .139 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146 HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . .147 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148

Chapter 13 Eye and Ocular Adnexa, Auditory Systems . . . . 223

The Eye: Introduction and Anatomy . . . . . . .223 The Ear: Introduction and Anatomy . . . . . . 224 ICD-9-CM Coding . . . . . . . . . . . . . . . . . . . . . .225 CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . .227 Medicine Codes . . . . . . . . . . . . . . . . . . . . . . . 228 HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . .229 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229

Chapter 9 Digestive System . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . .155 Anatomy and Medical Terminology . . . . . . .155 ICD-9-CM Coding . . . . . . . . . . . . . . . . . . . . . .156 CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . .158 HCPCS Level II Coding . . . . . . . . . . . . . . . . . .162 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162

Chapter 10 Urinary System and Male Genital System . . . . . 169

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . .169 Anatomy and Medical Terminology . . . . . . .169 ICD-9-CM Coding . . . . . . . . . . . . . . . . . . . . . .171 CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . .175 HCPCS Level II . . . . . . . . . . . . . . . . . . . . . . . . .180 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181

Chapter 14 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . .235 Types of Anesthesia . . . . . . . . . . . . . . . . . . . . .235 Anesthesia Coding Terminology . . . . . . . . . 236 Postoperative Pain Management . . . . . . . . . 236 ICD-9-CM Coding . . . . . . . . . . . . . . . . . . . . . .237 CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . .237 Anesthesia-Related Teaching Rules . . . . . . . 242 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

Chapter 11 Female Reproductive System . . . . . . . . . . . . . . . . 189

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . .189 Anatomy and Medical Terminology . . . . . . .189 ICD-9-CM Coding . . . . . . . . . . . . . . . . . . . . . .190 CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . .192 HCPCS Level II Coding . . . . . . . . . . . . . . . . . .195 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195

Chapter 15 Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 249 Anatomy and Medical Terminology . . . . . . 249 ICD-9-CM Coding . . . . . . . . . . . . . . . . . . . . . 250 CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . .251 Types of Radiological Services . . . . . . . . . . . .252 The Components of a Radiology Service . . . . . . . . . . . . . . . . . . . . .253 Diagnostic Ultrasound . . . . . . . . . . . . . . . . . .253

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Contents

Radiologic Guidance . . . . . . . . . . . . . . . . . . . 254 Breast, Mammography . . . . . . . . . . . . . . . . . .255 Bone/Joint Studies . . . . . . . . . . . . . . . . . . . . . .255 Radiation Oncology . . . . . . . . . . . . . . . . . . . . .255 Nuclear Medicine . . . . . . . . . . . . . . . . . . . . . . 256 HCPCS Level II Coding . . . . . . . . . . . . . . . . . 256 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .257

Chapter 16 Pathology and Laboratory . . . . . . . . . . . . . . . . . . . 263

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . .263 Anatomy and Medical Terminology . . . . . . .263 ICD-9-CM Coding . . . . . . . . . . . . . . . . . . . . . 264 CPT® Coding . . . . . . . . . . . . . . . . . . . . . . . . . . .265 HCPCS Level II Coding . . . . . . . . . . . . . . . . . .269 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .269 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .270

Chapter 17 Evaluation and Management . . . . . . . . . . . . . . . . 275

Introduction and Objectives . . . . . . . . . . . . . .275 Defining E/M Services . . . . . . . . . . . . . . . . . . .275 CPT® E/M Services Guidelines . . . . . . . . . . . .276 The Key Components of an E/M Service . . . . . . . . . . . . . . . . . . . . . . .276 E/M Service Categories . . . . . . . . . . . . . . . . . .277 Choosing an E/M Service Level . . . . . . . . . . 284 Diagnosis Coding for E/M Services . . . . . . . .297 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .298

Chapter 18 Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

Anti-infective Immunizations . . . . . . . . . . . 305 Vaccines and Toxoids . . . . . . . . . . . . . . . . . . . 306 Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306 Biofeedback . . . . . . . . . . . . . . . . . . . . . . . . . . . 306 Dialysis and End Stage Renal Disease Services . . . . . . . . . . . . . . . . . . 306 Gastroenterology . . . . . . . . . . . . . . . . . . . . . . 307 Ophthalmological Services & Special Otorhinolaryngologic Services . . . . . . . . . . . . . . . . . . . 307 Cardiovascular Services . . . . . . . . . . . . . . . . 307

Noninvasive Vascular Diagnostic Studies . . . . . . . . . . . . . . . . . . . . . 307 Pulmonary Studies . . . . . . . . . . . . . . . . . . . . . 307 Allergy and Immunology . . . . . . . . . . . . . . . 308 Endocrinology & Neurology and Neuromuscular Procedures . . . . . . . . . 308 Medical Genetics and Genetic Counseling Services . . . . . . . . . . . . 308 Central Nervous System Assessments/Tests . . . . . . . . . . . . . . . 308 Hydration, Therapeutic, Prophylactic, Diagnostic Injections/Infusions and Chemotherapy, Highly Complex Drugs or Highly Complex Biologic Agent Administration . . . . . . . . . . . . . . . . . . 308 Photodynamic Therapy & Special Dermatological Procedures . . . . . . . .310 Physical Medicine and Rehabilitation . . . . . .310 Education and Training for Patient Self-Management . . . . . . . . . . . . .311 Non-Face-to-Face Nonphysician Services . . . . . . . . . . . . . . . . . . .311 Special Services, Procedures, and Reports . . . . . . . . . . . . . . . . .312 Qualifying Circumstances for Anesthesia & Moderate (Conscious) Sedation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .313 Other Services and Procedures . . . . . . . . . . .313 Home Health Procedures and Services . . . . . . . . . . . . . . . . .313 Home Infusion Procedures . . . . . . . . . . . . . . .315 Medication Therapy Management Services . . . . . . . . . . . . . . . . . . .315 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .315

Chapter 19 Tips for Taking an AAPC Certification Exam . . 323

CPC® Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . .323 Preparing for Your Exam . . . . . . . . . . . . . . . .323 Exam Registration . . . . . . . . . . . . . . . . . . . . . .324 Day of the Exam . . . . . . . . . . . . . . . . . . . . . . . .324 During the Test . . . . . . . . . . . . . . . . . . . . . . . . .324 Exam Completion . . . . . . . . . . . . . . . . . . . . . . .325

CPT ® copyright 2010 American Medical Association. All rights reserved.

2011 CPC Certification Study Guide

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Chapter

Chapter 20 Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . 327 Appendix A Answers and Rationales for Chapter Review Questions . . . . . . . . . . . . . . . 341

Chapter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .341 Chapter 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Chapter 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344 Chapter 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346 Chapter 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .347 Chapter 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .350 Chapter 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .352 Chapter 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .354 Chapter 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .357 Chapter 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .359 Chapter 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .361 Chapter 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .363 Chapter 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .365 Chapter 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .367 Chapter 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .370 Chapter 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .371 Chapter 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .373 Chapter 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .376

Appendix B Answers and Rationales for Test Your Knowledge . . . . . . . . . . . . . . . . . . . . 379

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