Being a Medical Information Coder / Edition 3

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Overview

This book provides an introduction to ICD-9-CM coding that is easy to read and understand but covers basic coding principles comprehensively. With its focus on diagnosis, symptoms, and procedures related to these systems, coding principles are introduced and reinforced throughout. This book provides in-depth coverage of ICD-9-CM coding for medical information professionals, and discusses procedure codes, anatomy, physiology, pathophysiology, medical record content, and computer use. A valuable reference tool for Registered Health Information Technologists (RHITs) and Credentialed Coding Specialists (CCSs).

The book contains black-and-white illustrations.

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Product Details

  • ISBN-13: 9780131126756
  • Publisher: Prentice Hall
  • Publication date: 5/15/2003
  • Series: Prentice Hall Health Medical Clerical SE
  • Edition description: Subsequent
  • Edition number: 3
  • Pages: 288
  • Product dimensions: 8.30 (w) x 10.90 (h) x 1.20 (d)

Meet the Author

Laurie Dodson, RHIA, MPH, received her graduate degree from UCLA's School of Public Health with an emphasis on Health Information Systems. For the past 23 years she has been an instructor in Cypress College's Health Information Technology program in California, where she has taught classes in entry-level coding with ICD9-CM. She therefore recognizes many of the problem areas where students have trouble with coding.

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Read an Excerpt

While many American industries seem to be in decline, the health care industry is growing. With an aging population needing more attention and with new technologies revolutionizing the delivery of health care, the industry is "healthy."

Information is an especially necessary commodity for success. Top managers need statistics to aid in decision-making activities. To determine the effectiveness of treatments and diagnostic tools, physicians need information. Government agencies on both the federal and state levels use comparative data to monitor quality of care, and insurance companies need information in order to evaluate claims and plan for the future. The health information specialist is trained and ready to meet these ever-growing demands.

Coders have long played a role in making it possible to store and retrieve health information. With the federal government's prospective payment system, which relies on complete, accurate coding using the ICD-9-CM coding system, the role has taken on added importance.

Previously, reimbursement depended on length of stay and diagnostic procedures performed. Now, medical information coders are required to review medical records looking for ways to optimize potential reimbursement. Their skills are of utmost importance, and job opportunities abound. Each day offers new ways in which health information specialists can demonstrate their value and impact on the successful delivery of health care.

This book is part of a series developed by Prentice Hall to introduce the student to the ever-growing opportunities evident in the health information departments throughout the health care industry. Other books in the series address hospital admitting, insurance billing (which includes CPT coding), and medical transcription.

Chapter 1 introduces the student to the medical information coder and to the medical record as a source document for gathering information. Chapter 2 introduces the student to ICD-9-CM, the international coding system modified for use in the United States and used to record both diagnoses and procedures in the inpatient setting.

Chapters 3 to 22 take the student step by step through the coding system, pointing out guidelines and problem areas and demonstrating key concepts. At the conclusion of each chapter are exercises that provide opportunities for the student to code health information using newfound skills.

Chapter 23 gives the student an overview of the prospective payment system endorsed by the federal government in reimbursement efforts for Medicare patients. Any medical information coder must expand his or her knowledge of this system, because the financial wellbeing of facilities partially depends on the coding skills of these important people.

Chapter 24 portrays differences between coding in the inpatient setting and the outpatient or ambulatory setting. While many of the codes are the same, some coding rules differ and must be recognized in order to provide accurate and complete codes.

Chapter 25 addresses the need for coding compliance managers. The 1996 Health Insurance Portability and Accountability Act (HIPPA) gave added importance to coding accuracy, therefore ongoing monitoring systems must be in place to screen codes for fraud and abuse and look at high risk areas such as alcohol and drug abuse, HIV, and cancer. Compliance managers must coordinate the activities of physicians, coders, and other health care providers to make sure that health information is accurate, confidential, and documented.

Coding is an exciting career opportunity for enthusiastic people with a keen interest in health information. I hope that this book will start many on their way to new horizons in coding.

Laurie Dodson

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Table of Contents

1. Introduction to the Medical Information Coder.

2. Introduction to ICD-9-CM Coding.

3. Procedure Codes.

4. Infectious and Parasitic Disease.

5. Neoplasms.

6. Endocrine, Nutritional, and Metabolic Disease and Immunity Disorders.

7. Blood and Blood-Forming Organs.

8. Mental Disorders.

9. Diseases of the Nervous and Sense Organs.

10. Diseases of the Circulatory System.

11. Diseases of the Respiratory System.

12. Diseases of the Digestive System.

13. Diseases of the Genitourinary System.

14. Complications of Pregnancy, Childbirth, and the Puerperium.

15. Certain Conditions Originating in the Perinatal Period.

16. Congenital Anomalies.

17. Diseases of the Skin and Subcutaneous Tissue.

18. Diseases of the Musculoskeletal System and Connective Tissues.

19. Symptoms, Signs, and Ill-Defined Conditions.

20. Injury and Poisoning.

21. External Causes of Injury and Poisoning.

22. V-Codes.

23. Diagnosis-Related Groups.

24. Ambulatory Coding.

25. Coding Compliance.

Appendix: Coding Specialist Certification Program.

References.

Index.

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Preface

While many American industries seem to be in decline, the health care industry is growing. With an aging population needing more attention and with new technologies revolutionizing the delivery of health care, the industry is "healthy."

Information is an especially necessary commodity for success. Top managers need statistics to aid in decision-making activities. To determine the effectiveness of treatments and diagnostic tools, physicians need information. Government agencies on both the federal and state levels use comparative data to monitor quality of care, and insurance companies need information in order to evaluate claims and plan for the future. The health information specialist is trained and ready to meet these ever-growing demands.

Coders have long played a role in making it possible to store and retrieve health information. With the federal government's prospective payment system, which relies on complete, accurate coding using the ICD-9-CM coding system, the role has taken on added importance.

Previously, reimbursement depended on length of stay and diagnostic procedures performed. Now, medical information coders are required to review medical records looking for ways to optimize potential reimbursement. Their skills are of utmost importance, and job opportunities abound. Each day offers new ways in which health information specialists can demonstrate their value and impact on the successful delivery of health care.

This book is part of a series developed by Prentice Hall to introduce the student to the ever-growing opportunities evident in the health information departments throughout the health care industry. Other books in the series address hospital admitting, insurance billing (which includes CPT coding), and medical transcription.

Chapter 1 introduces the student to the medical information coder and to the medical record as a source document for gathering information. Chapter 2 introduces the student to ICD-9-CM, the international coding system modified for use in the United States and used to record both diagnoses and procedures in the inpatient setting.

Chapters 3 to 22 take the student step by step through the coding system, pointing out guidelines and problem areas and demonstrating key concepts. At the conclusion of each chapter are exercises that provide opportunities for the student to code health information using newfound skills.

Chapter 23 gives the student an overview of the prospective payment system endorsed by the federal government in reimbursement efforts for Medicare patients. Any medical information coder must expand his or her knowledge of this system, because the financial wellbeing of facilities partially depends on the coding skills of these important people.

Chapter 24 portrays differences between coding in the inpatient setting and the outpatient or ambulatory setting. While many of the codes are the same, some coding rules differ and must be recognized in order to provide accurate and complete codes.

Chapter 25 addresses the need for coding compliance managers. The 1996 Health Insurance Portability and Accountability Act (HIPPA) gave added importance to coding accuracy, therefore ongoing monitoring systems must be in place to screen codes for fraud and abuse and look at high risk areas such as alcohol and drug abuse, HIV, and cancer. Compliance managers must coordinate the activities of physicians, coders, and other health care providers to make sure that health information is accurate, confidential, and documented.

Coding is an exciting career opportunity for enthusiastic people with a keen interest in health information. I hope that this book will start many on their way to new horizons in coding.

Laurie Dodson

Read More Show Less

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